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PSYCHOTHERAPEUTICS 


Psychotherapeutics 


A  SYMPOSIUM 


BY 
MORTON  PRINCE,  M.  D. 

ProfeMor  of  Diseases  of  the  Nervous  Swtem,  Tufts  College  Medical  School 

FREDERIC  H.  GARISH,  M.  D. 

Professor  of  Surgery,  Bowdoin  College 

JAMES  J.  PUTNAM,  M.  D. 

Professor  of  Neurology,  Harvard  Medical  School 

E.  W.  TAYLOR,  M.  D. 

Instructor  in  Neurology,  Harvard  Medical  School 

BORIS  SIDIS,  M.  D. 
GEORGE  A.  WATERMAN,  M.  D. 

Assistant  in  Neurology,  Harvard  Medical  School 

JOHN  E.  DONLEY,  M.  D. 

Physician  of  Nervous  Diseases,  St.  Joseph's  Hospital,  Providence 

ERNEST  JONES,  M.  D. 

Demonstrator  of  Psychiatry,  University  of  Toronto 

TOM   A.  WILLIAMS,  M.  D. 


SANTA    BARBARA.   CALIF. 

fc*-  *        1    %     k     ^\         te*"    \*   \t--J    ^J    V/^A  «         X»*4^^— »<»      ^ 

BOSTON  &  TORONTO 

RICHARD  G.  BADGER 

3£f)t  &or|)3ni  ^rtss 

1910      r^\ 


Copyright,  1909,  by  Richard  G.  Badger 


All  Rights  Reserved 


The  Gorham  Press,  Boston,  U.  S.  A. 


PREFACE 


THIS    scries   of  papers   originally   formed    a   sym- 
posium and  were  read  before  the  American  Thera- 
peutic  Society  at  its  annual  meeting  held  at  New 

Haven,  May  6,  7,  and  8,  1909.     They  are  now 
published  in  this  form  through  the  courtesy  of  their  authors 
and  THE  JOURNAL  OF  ABNORMAL  PSYCHOLOGY  in  which  ? 
they  originally  appeared. 


CONTENTS 

Page 

I.    Introduction       .          .          .          .          .          .  9 

II.    The  Psychological  Principles    and  Need    of 

Psychotherapy                 .          .          .          .  II 

Complex  Formation           .         .         .         .  17 

Conservation             .....  22 

Dissociation  .          .         .         .         .26 

Automatism              .         <         .         .         .  30 

Emotional  Energy    .          .          .          .          .  32 

The  Relative  Advantages  of  Education  in 

Hypnosis  and  in  the  Waking  State     .          .  37 

Hysteria           ......  42 

Psychasthenia  and  Obsessions    ...  46 

III.  The  Therapeutic  Value  of  Hypnotic  Suggestion  47 

Methods  of  Inducing  Hypnosis  ...  52 
Conditions  in  which  Hypnotic  Suggestion  is 

Valuable  .  .  .  .  57 
Correction  of  Misconceptions  concerning 

Hypnotism            .....  65 

IV.  Simple  Explanation    and  Re-education  as  a 

Therapeutic  Method           ....  75 

V.    The  Treatment  of  Fatigue  States              .          .  87 

Physiological  Fatigue         ....  90 

Psychological  Fatigue        ....  92 

Psychopathological  Fatigue         .         .          .  94 

VI.    Psycho- Analysis  in  Psychotherapy        .          .  105 

VII.    The  Psychotherapeutic    Value   of  the   Hyp- 

noidal  State     .          .          .          .  119 

VIII.    Obsessions  and  Associated  Conditions  in  So- 
Called  Psychasthenia    .          .          .          .  145 

IX.    Psychoprophylaxis  in  Childhood           .          .  159 

X.    The   Relation   of  Character   Formation   to 

Psychotherapy 183 


INTRODUCTION  * 

IN  the  endeavor  to  learn  what  subjects  most  interested 
the  members  of  our  society,  and  what,  therefore,  it 
would  be  best  to  place  upon  the  program  of  this  meet- 
ing, I  wrote  to  almost  all  of  them  last  winter,  asking 
each  to  suggest  topics  for  the  three  symposia,  which  it  seemed 
desirable  to  arrange.  To  this  appeal  there  were  many 
responses,  which  indicated  a  wide  range  of  interests  and  a 
gratifying  alertness  to  descry  new  remedial  measures. 
Several  of  my  correspondents  proposed  psychotherapy; 
and  this  suggestion  coincided  perfectly  with  the  purpose 
which  I  had  already  formed  to  have,  if  possible,  a  discussion 
on  this  subject,  which  has  not  previously  been  presented  at 
our  meetings,  and  is  of  such  importance  that  every  medical 
practitioner,  whatever  his  favorite  line  of  work,  should  be 
well  grounded  in  its  principles  and  familiar  with  its  methods. 
Its  presentation  is  generally  a  grotesque  mixture  of  fact  and 
fancy,  of  truth  and  error,  the  good  and  bad  so  speciously 
blended  as  to  make  the  product  at  once  alluring  and  danger- 
ous to  untrained  minds.  Indeed,  most'  physicians  and  some 
neurologists  have  little  appreciation  of  this  branch  of  the 
healing  art,  and  treat  it  cavalierly,  if  they  deign  to  give  it  any 
consideration.  The  time  seemed  opportune  for  a  careful, 
serious,  scientific  study  of  the  subject  by  this  society,  the 
only  national  organization  in  America  devoted  exclusively  to 
therapeutics.  Furthermore,  it  was  plain  to  me  that  this 
association,  whose  single  purpose  is  so  conspicuously  declared 

*  [Prefatory  Note  :  In  his  address  as  President  of  the  American  Thera- 
peutic Society,  Dr.  Frederic  Henry  Gerrish  discoursed  on  "  The  Therapeutic 
Value  of  Hypnotic  Suggestion,"  beginning  his  essay  with  a  statement  of  the 
origin  and  purpose  of  this  symposium.  These  explanatory  remarks  serve  so 
aptly  as  an  introduction  to  this  series  of  papers  that,  with  permission,  they 
have  been  transposed  to  this  place.  THE  EDITOR.] 


IO  Introduction 

by  its  name,  was  under  a  peculiar  obligation  to  the  profession 
in  the  premises,  and  ought,  as  far  as  possible,  to  correct  the 
misapprehensions  which  prevail  concerning  psychotherapy, 
and  accord  the  sanction  of  its  interest  and  influence  to  this 
v  valuable  form  of  treatment.  By  great  good  fortune  the  aid 
of  eight  physicians  was  enlisted  in  this  cause,  all  of  whom  are 
learned  in  modern  psychology,  expert  in  neurology,  skilful 
in  psychotherapy,  and  enthusiastic  in  expounding  their 
favorite  doctrines.  They  constitute  a  galaxy,  which  cannot  be 
duplicated  on  this  continent.  Their  symposium,  which  will 
occupy  the  entire  afternoon  to-morrow,  will  be  most  illuminat- 
ing and  well  worthy  of  your  earnest  and  studious  attention. 
Before  it  was  known  that  a  satisfactory  symposium  on 
psychotherapy  could  be  arranged,  I  had  determined  to  con- 
sider one  phase  of  it  in  the  address,  which  custom  requires 
your  president  to  make,  and  this  for  several  reasons:  it  is 
as  far  as  possible  from  the  hackneyed;  it  ought  to  interest 
and  be  understood  by  every  medical  practitioner;  it  is  the 
least  comprehended  of  the  psychotherapeutic  methods;  that 
to  which  the  most  strenuous  and  even  savage  opposition  is 
habitually  made,  and  that,  therefore,  which  needs  the  most 
explanation  and  defense;  it  is  almost  uniformly  treated 
unjustly  because  ignorantly;  and  finally,  it  has  been  the 
subject  of  so  much  study  and  observation  on  my  own  part 
that  on  no  other  topic  of  general  medical  importance  did  I 
feel  as  well  qualified  to  speak  to  you  with  an  approximation 
to  authority.  Many  years  ago,  when  I  had  a  considerable 
general  practice,  I  used  this  psychic  agency  very  extensively 
for  a  long  time;  and  while  the  concentration  of  my  energies 
on  another  branch  has  necessitated  the  abandonment  of  this 
and  some  other  lines  of  therapeutic  activity,  my  interest  in 
this  subject  is  still  strong,  and  my  desire  to  have  it  under- 
stood and  employed  by  the  profession  is  undiminished. 
Therefore,  I  ask  your  attention  for  a  little  time  this  morning 
to  the  therapeutic  value  of  hypnotic  suggestion. 


THE  PSYCHOLOGICAL  PRINCIPLES  AND  FIELD 
OF  PSYCHOTHERAPY 

BY   MORTON   PRINCE,   M.BlJJ 

Professor  of  Diseases  of  the  Nervous 
Tufts  College  Medical  School 


THE  PSYCHOLOGICAL  PRINCIPLES  AND  FIELD 
OF  PSYCHOTHERAPY 

SO  much  that  is  pseudo-scientific  or  mere  platitude,  so 
many  misstatements  have  been  set  forth  in  the  lay 
and  medical  press  both  by  those  who  are  the  advo- 
cates of  psychotherapy  and  by  those  who    are  its 
critics;   so  many  erroneous  ideas  abound  regarding  both  the 
nature  of  the  disturbances  of  the  mind  and  body  which  we 
seek  to  allay  and  the  modes  by  which  we  endeavor  to  do  it, 
that  it  is  not  to  be  wondered  at  that  the  facts  of  observation 
have  been  mistrusted  and  the  methods  of  therapeutics  have 
met  with  cynical  criticism. 

If  we  are  to  judge  the  soundness  of  the  theory  on  which 
this  mode  of  treatment  is  based,  the  field  of  its  usefulness, 
its  limitations,  and  the  methods  of  its  application,  it  is  abso- 
lutely necessary  that  we  should  begin  any  discussion  of 
psychotherapy,  in  a  symposium  of  this  kind,  with  an  under- 
standing of  its  underlying  principles.  There  are  certain 
facts  of  observation  with  which  we  may  begin. 

I.  It  will  be  agreed  that  common  experience  has 
shown  that  certain  unhealthy  habitual  states  of  mind  are 
apt  to  be  accompanied  by  various  derangements  of  the 
functions  of  the  body.  By  "  unhealthy  "  I  would  designate 
those  which  tend  to  misadapt  a  person  to  his  environment, 
and  among  these  habits  or  states  of  mind  I  would  classify 
depressive  or  disruptive  emotions  and  feelings;  apprehen- 
sions, and  fear  of  disease  or  of  the  consequences  of  business 
or  social  acts;  fixed  beliefs  in  fictitious  disease;  illogical 
doubts,  scruples,  and  anxieties;  habits  of  thought  such  as 
constant  introspection,  self-consciousness,  the  concentration 
of  the  attention  on  the  physiological  functions  of  the  body, 
the  expectation  of  ill  consequences  following  any  course 
of  conduct,  and  so  on.  I  need  not  go  into  details,  for  that 

'3 


H  Psyehothtraptutics 

such  conditions  of  mind  are  accompanied  by  derangements  of 
the  bodily  functions  is  a  fact  of  common  knowledge  which 
is  confirmed  by  the  experience  of  laymen  as  well  as  physicians 
and  psychologists.  Furthermore,  in  certain  persons  the 
modes  of  mental  activity  I  have  described  if  frequently  re- 
peated tend  to  become  habits  or  habitual  reactions  to  the 
environment  that  are  not  easily  discarded.  Often  the  mental 
states  when  persistent  and  intense  become  disabilities  in 
themselves,  constituting  veritable  psychoses,  such  as  the 
anxiety  psychosis,  phobias  of  various  kinds,  morbid  shyness 
and  self-consciousness,  association  psychoses,  etc.  It  is  not 
to  be  affirmed  that  these  unhealthy  mental  states  of  mind,  even 
when  they  become  habitual  psychoses,  are  accompanied  in 
every  individual  by  disturbance  of  bodily  functions,  but  the 
tendency  is  such  in  persons  of  a  certain  temperament  and 
so-called  nervous  organization. 

2.  It  is  also  a  fact  of  observation  which  is  too  well 
admitted  to  be  mistrusted  that,  when  healthy  mental  states 
are  substituted  for  unhealthy  ones  of  the  character  I  have 
described,  the  functional  derangements  of  the  body  tend  to 
disappear. 

The  two  classes  of  facts  just  enumerated  become  com- 
prehensible when  we  remember  that  physiological  and 
clinical  observations  have  shown  that  temporary  or  passing 
mental  states  when  accompanied  by  strong  feeling  tones 
often  alter  in  a  marked  degree  the  various  visceral  functions. 
To  mention  but  a  few  of  these  effects :  The  increase  of  the 
heart's  action;  the  increase  of  the  blood  pressure;  the  varia- 
tions of  the  vasomotor  system;  the  increased  muscular 
energy  and  feeling  of  wellbeing;  the  pouring  out  of  the 
appetite  juice  and  saliva  (Pawlow),  etc.,  through  the  influ- 
ence of  ideas  associated  with  sthenic  pleasurable  emotions  — 
all  these  have  been  attested  by  the  observations  of  the  physi- 
ologist and  of  the  clinician.  Per  contra,  the  suppression  of 
salivary  and  gastric  secretions;  the  inhibition  of  peristalsis 


The  Psychological  Principles  and  Field  of  Psychotherapy  15 

and  segmentation;  the  contraction  and  dilatation  of  the 
blood  vessels;  the  increased  functions  of  the  sweat  glands; 
the  alteration  in  the  rhythm  and  rapidity  of  the  respiration 
and  heart's  action;  the  inhibition  of  many  functions  (gastro- 
intestinal); the  decrease  of  muscular  energy;  the  awakening 
of  the  sense  and  symptoms  of  fatigue;  these  and  many  such 
phenomena  have  been  shown  by  carefully  recorded  tests  to 
accompany  the  temporary  excitation  of  ideas  that  are  associa- 
ated  with  depressing  and  painful  emotions.  That  the  per- 
sistence of  such  mental  states  should  be  accompanied  by 
persistent  disturbance  of  function  is  not  to  be  wondered  at. 

3.  A  third  class  of  facts  must,  I  think,  also  be  accepted 
as  proven;  namely,  that  emotional  shocks  are  apt  in  certain 
persons  to  leave  persisting  after-effects  manifested  by  dis- 
turbances of  function  of  the  nervous  system.     We  need  not 
inquire  at  this  moment  into  the  exact  nature  of  these  disturb- 
ances or  give  them  a  name.     It  is  generally  agreed  that  they 
are  of  the  character  which  is  called  functional  and  owe  their 
evolution  to  the  principles  which  I  will  presently  describe. 
In  their  most  obtrusive  form  they  are  observed  as  the  trau- 
matic neuroses  (psychoses). 

4.  A  fourth  class  of  facts  is  of  importance  for  psycho- 
therapeutics,  viz.:    In  all  persons  to  a  certain  extent  and  in 
some  persons  to  a  large  extent  suggested  ideas  tend  to  work 
themselves   out  to   fulfilment.     In   certain   diseased   states 
(hysteria)    and   in   certain   artificial   states    (hypnosis)    this 
tendency  reaches  a  maximum  and,  consequently,  by  sugges- 
tion, intentionally  given  to  persons  in  such  conditions,  dis- 
turbances of  function  can  be  produced  artificially  and  re- 
moved again.     Likewise  ideas  originating  in  the  mind  of  the 
person   himself  may   induce   the   same   phenomena    (auto- 
suggestion).    Thus    on    the    physiological    side    functional 
paralysis,  contractures,  anesthesias,  spasms,  etc.;     and  on 
the  mental  side  amnesias,  hallucinations,  sleep,  trains  of 
ideas  and  feeling,  etc.,  can  be  artificially  produced  and  after- 


1 6  Psychotherapeuttcs 

wards  modified  and  removed.  In  this  statement  I  am  not 
including  the  basic  condition,  whatever  it  may  be,  that  gives 
rise  to  the  increased  suggestibility,  but  to  the  phenomena 
resulting  from  suggestion.  How  far  that  condition  comes 
within  the  influence  of  suggestion  is  another  question  to 
which  I  will  later  return.  The  phenomena  of  suggestion 
have  been  determined  by  experiment  over  and  over  again, 
while  the  history  of  medicine  testifies  to  the  occurrence  of 
such  phenomena  under  accidental  conditions.  Indeed  a 
distinguished  neurologist  (Babinski)  has  recently  advanced 
the  thesis,  though  as  I  believe  erroneously,  that  all  hysteria  is 
nothing  but  a  group  of  suggested  symptoms. 

We  cannot  be  too  cautious  in  generalizing  from  limited 
facts  of  this  kind  which  are  observed  under  special  condi- 
tions, but  the  basic  principle  is  of  great  importance  and  one 
that  obviously  can  be  made  use  of  in  psychotherapeutics. 
To  what  extent  it  can  be  used  is  another  question  that 
can  only  be  determined  by  experience. 

After  this  general  statement  of  certain  fundamental 
facts  of  observation  I  would  call  attention  to  certain  princi- 
ples, if  not  laws,  which  observation  has  shown  govern  the 
functioning  of  the  nervous  system. 


The  Psychological  Principles  and  Field  of  Psychotherapy  1 7 
I.      COMPLEX  FORMATION 

It  is  a  law  that  associated  ideas,  feelings,  emotions, 
sensations,  movements,  visceral  functions  of  whatever  kind, 
tend,  after  constant  repetition  or  when  accompanied  by 
strong  emotion  and  feeling  tones,  and  under  other  conditions, 
to  become  linked  together  into  a  system  or  group  in  such 
fashion  that  the  stimulation  of  one  element  in  the  group 
stimulates  the  activity  of  the  rest  of  the  group.  Such  a  group 
is  conveniently  called  a  complex,  and  as  such  I  shall  hereafter 
refer  to  it.  This  tendency  to  linking  of  functions  obtains 
whether  the  mental  and  physiological  processes  when  linked 
form  a  complex  which  subserves  the  wellbeing  of  the  organ- 
ism and  adapts  the  individual  to  his  environment,  or  whether 
they  form  one  which  does  not  subserve  the  wellbeing  of  the 
individual,  but  misadapts  him  to  his  environment.  In  the 
former  case  the  complex  is  called  normal,  in  the  latter  ab- 
normal. This  is  only  another  aspect  of  the  well-accepted 
principle  that  pathological  processes  are  normal  processes 
functioning  under  altered  conditions.  Both  are  the  expres- 
sion of  one  and  the  same  mechanism. 

The  linking  of  function  may  be  almost  entirely  of  ideas, 
as  is  expressed  by  the  well-known  psychological  law  of"  asso- 
ciation of  ideas."  Its  pathological  manifestations  we  see  in 
so-called  fixed  ideas  or  obsessions.  We  see  it  also  exem- 
plified within  normal  limits  in  so-called  moods,  when  certain 
large  systems  of  ideas  accompanied  by  strong  emotion  tones 
occupy  the  mental  field  to  the  exclusion  of  other  systems 
which  find  it  difficult  to  take  possession  of  the  field  of  con- 
sciousness. When  such  moods  are  developed  and  intensi- 
fied to  an  extreme  degree  we  have  veritable  pathological 
alterations  of  personality  and  even,  it  may  be,  multiple 
personality.  But  in  moods  besides  association  we  meet 
with  another  principle  in  an  exaggerated  form,  namely, 
dissociation.  Of  this  I  will  presently  speak. 


1 8  Psychotherapeutics 

The  linking  again  may  be  of  physiological  processes 
as  exemplified  by  synergesis  of  muscular  movements.  This 
is  seen  in  the  linked  combination  of  muscles  used  in  writing, 
piano  playing,  skilled  use  of  tools,  and  implements  of  games 
(golf,  tennis,  etc.).  Even  the  simpler  movements  of  a  finger, 
hand,  or  arm  require  the  coaptative  synergesis  of  several 
muscles.  These  synergetic  movements  are  admittedly  the 
result  of  education  through  repetition,  although  undoubtedly 
the  compound  cerebro-spinal  reflexes  so  beautifully  studied 
and  brought  to  light  by  Sherrington  are  made  use  of. 

The  possibility  of  organizing  physiological  processes  into 
memories  by  artificial  means  and  linking  them  to  psychological 
processes  is  shown  very  neatly  by  the  extremely  important  experi- 
ments of  Pawlow  and  his  co-workers  on  the  reflex  stimulation 
of  saliva  in  dogs.  The  facts  which  I  wish  here  to  recite  are  thus 
described  by  Pawlow: 

"  In  the  course  of  our  experiments  it  appeared  that  all  the 
phenomena  of  adaptation  which  we  saw  in  the  salivary  glands 
under  physiological  conditions,  such,  for  instance,  as  the  intro- 
duction of  the  stimulating  substances  into  the  buccal  cavity,  re- 
appeared in  exactly  the  same  manner  under  the  influence  of  psy- 
chological conditions  —  that  is  to  say,  when  we  merely  drew  the 
animal's  attention  to  the  substances  in  question.  Thus,  when  we 
pretended  to  throw  pebbles  into  the  dog's  mouth,  or  to  cast  in  sand, 
or  to  pour  in  something  disagreeable,  or,  finally,  when  we  offered  it 
this  or  that  kind  of  food,  a  secretion  either  immediately  appeared 
or  it  did  not  appear,  in  accordance  with  the  properties  of  the  sub- 
stance which  we  had  previously  seen  to  regulate  the  quantity  and 
nature  of  the  juice  when  physiologically  excited  to  flow.  If  we  pre- 
tended to  throw  in  sand,  a  watery  saliva  escaped  from  the  mucous 
glands;  if  food,  a  slimy  saliva,  and  if  the  food  were  dry  —  for  ex- 
ample, dry  bread  —  a  large  quantity  of  saliva  flowed  out,  even  when 
it  excited  no  special  interest  on  the  part  of  the  dog.  When,  on  the 
other  hand,  a  moist  food  was  presented  —  for  example,  flesh, — 
much  less  saliva  appeared  than  in  the  previous  case,  however 
eagerly  the  dog  may  have  desired  the  food.  This  latter  effect  is 
particularly  obvious  in  the  case  of  the  parotid  gland."* 

More  than  this  the  psychical  excitation  may  be  part  of  a 
wider  complex;  everything  that  is  in  any  way  psychologically  asso- 

*The  work  of  the  Digestive  Glands  (English  Translation),  p.  152. 


The  Psychological  Principles  and  Field  of  Psychotherapy  19 

ciated  with  an  object  which  physiologically  excites  the  saliva  reflex 
may  also  produce  it, —  the  plate  which  customarily  contains  the 
food,  the  furniture  upon  which  it  stands,  the  person  who  brings 
it,  even  the  sound  of  the  voice  and  sound  of  the  steps  of  this  person.* 

"  Any  ocular  stimulus,  any  desired  sound,  any  odor  that 
might  be  selected,  and  the  stimulation  of  any  part  of  the  skin,  either 
by  mechanical  means  or  by  the  application  of  heat  or  cold,  have 
in  our  hands  never  failed  to  stimulate  the  salivary  glands,  although 
they  were  all  of  them  at  one  time  supposed  to  be  inefficient  for 
such  a  purpose.  This  was  accomplished  by  applying  these  stimuli 
simultaneously  with  the  action  of  the  salivary  glands,  this  action 
having  been  evolved  by  the  giving  of  certain  kinds  of  food  or  by 
forcing  certain  substances  into  the  dog's  mouth. "f 

It  is  obvious  that  reflex  excitation  thus  having  been  accom- 
plished by  the  education  of  the  nerve  centers  to  a  previously  in- 
different stimulus  the  reproduction  of  the  process  through  this 
stimulus  is  in  principle  an  act  of  physiological  memory.  [Prince: 
The  Unconscious,  JOURNAL  OF  ABNORMAL  PSYCHOLOGY,  Oct. — 
Nov.,  1908.] 

In  man  as  an  example  may  be  cited  the  vesical  reflex 
which  may  similarly,  as  is  well  known,  be  educated  to  react 
to  the  sound  of  running  water. 

These  pathbreaking  demonstrations  of  Pawlow  furnish 
the  key  to  the  mechanism  of  many  neuroses  and  psychoses, 
for  indeed  the  educated  reactions  of  the  gastric  and  salivary 
glands  to  ordinarily  indifferent  stimuli  from  the  environment 
and  to  psychical  states  are  in  reality  nothing  but  an  artifi- 
cially created  psycho-neurosis  —  a  perversion  of  the  normal 
reactions.  Such  artificial  syndromes  render  comprehensible 
the  mechanism  of  such  neuroses  as  the  well-known  neurotic 
type  of  hay  fever  which  belongs  to  the  association  neuroses.? 

In  this  type  the  whole  physiological  group  of  functions 

*J.  P.  Pawlow:  Psychische  Erregung  der  Speicheldriisen,  Ergebnisse 
der  Physiologie,  I()O$,I  Abteil,  p.  182. 

fHuxley  Lecture,  Br.  Med.  Jour.,  Oct.  6, 1906. 

JMorton  Prince:  Association  Neuroses,  Journal  of  Nervous  and 
Mental  Disease,  May,  1891. 

Morton  Prince:   Hay  Fever,  Due  to  Nervous  Influences,  Occurring 


20  Psychotherapeutics 

composing  the  neurosis  —  lachrymation,  congestion  of  the 
mucous  membranes  and  erectile  tissues,  secretions,  cough, 
dyspnoea,  etc., —  are  linked  into  an  automatically  working 
mechanism  by  repetition  and  excited  by  a  stimulus  from  the 
environment,  e.g.,  the  sight  of  a  rose  (which  may  be  artificial) 
dust,  sunlight,  etc.  Psychical  expectation  (auto-suggestion) 
of  course  prepares  and  keeps  alive  the  association.  This 
neurosis,  composed  mostly  of  physical  symptoms,  strikingly 
illustrates  the  principle  of  an  educated  functional  disease  and 
typifies  many  forms  of  neuroses. 

In  other  psycho-neuroses  the  syndrome  may  be  made  up 
partly  of  psychical  elements  and  partly  of  physical  processes. 
This  is  seen  in  psychasthenia,  where,  for  instance,  fears, 
anxieties,  scruples,  confusion  of  thought,  etc.,  are  associated 
with  all  sorts  of  disturbances  of  the  body, —  dizziness,  palpi- 
tation, tremor,  perspiration  —  the  whole  constituting  a 
phobia  or  anxiety  neurosis. 

Now  without  pursuing  these  illustrations  further,  the 
point  I  would  like  to  emphasize  is  that  the  whole  process  by 
which  these  functional  syndromes  are  created  is  educational. 
The  education  may  be  unintentional,  i.e.,  accidental,  as  in 
the  hay  fever  neurosis  and  those  resulting  from  continued 
auto-suggestion;  or  it  may  be  intentional,  as  in  Pawlow's 
experiments  on  the  digestive  functions. 

In  these  facts  which  I  have  only  incompletely  collated 
we  have  the  manifestations  of  a  broad  general  principle 
governing  nervous  processes  in  normal  and  abnormal  life. 
It  is  the  principle  of  pedagogy.  Unless  nervous  processes 
could  be  artificially  linked  into  coaptative  synergetic  systems 
adapted  to  a  purpose,  education  in  any  field  would  be  im- 

—  in  Five  Members  of  the  same  Family,  Annals  ofGyncecology  and  Pediatry, 
1895. 

John  E.  Donley:  Three  Cases  of  Association  Neuroses,  Boston 
Medical  and  Surgical  Journal,  November  3,  1904;  Study  of  Association 
Neuroses,  JOURNAL  OF  ABNORMAL  PSYCHOLOGY,  Vol.  II,  p.  45. 


The  Psychological  Principles  and  Field  of  Psychotherapy  21 

possible.  Intellectual  acquisitions,  from  the  repetition  of 
the  alphabet  to  a  complete  knowledge  of  a  language  or  a 
science,  and  physiological  acquisitions,  from  the  use  of  a  tool 
to  the  mastery  of  the  piano  or  the  vocal  apparatus,  not  only 
would  be  unknown  but  would  be  unthinkable.  The  educa- 
tion of  the  mind  and  body  depends  upon  the  artificial  synthe- 
sizing of  functions  into  a  complex  adapted  to  an  end  or  useful 
purpose.  By  the  same  principle  functions  may  be  synthe- 
sized by  education  into  a  complex  which  does  not  serve  a 
useful  purpose  but  rather  is  harmful  to  the  individual.  When 
this  is  the  case  we  call  it  abnormal  or  a  psycho-neurosis. 

From  this  point  of  view  how  inadequate  is  the  allegation 
which  we  often  see  stated  that  there  is  no  such  thing  as  a 
functional  disease.  What  can  be  the  conception  of  function 
which  must  be  held  by  those  who  maintain  such  a  theory  is 
something  that  passes  comprehension.  A  functional  disease 
is  a  perversion  of  the  normal  processes  brought  about  by  some 
acute,  intense  experience  or  by  repetition  of  an  experience, 
i.e.,  by  education.  Theoretically  it  would  follow  that  what 
can  be  done  by  education  can  be  undone  by  the  same  method, 
and  in  practice  we  find  this  to  be  true.  We  shall  presently  see 
that  there  are  often  types  of  functional  disease,  but  each  is 
based  on  a  perversion  of  the  normal  mechanism. 


22  Psychotherapeutics 

2.      CONSERVATION 

Another  principle  or  tendency  of  the  functioning  of  the 
nervous  system  has  been  firmly  established  by  repeated  ex- 
perimentation and  observation.  Its  importance  for  psycho- 
therapy can  hardly  be  exaggerated.  It  is  this:  All  our  ex- 
periences —  anything  that  we  have  thought,  seen,  heard,  or 
felt  —  tend  to  be  conserved  in  such  a  way  that  they  can  be 
reproduced  in  a  form  approaching  that  of  the  original  ex- 
perience. Upon  this  memory  depends.  It  is  evident  that 
we  never  could  remember  anything,  that  all  experiences  would 
be  lost  to  consciousness,  unless  somehow  and  somewhere  they 
were  preserved,  unless  there  was  some  physical  arrangement 
for  preserving  them.  In  what  form  mental  and  other  ex- 
periences are  conserved  we  do  not  know,  we  can  only  theorize; 
but  we  must  infer  that  some  kind  of  residue  or  impression, 
chemical  or  physical,  is  left  in  the  neurones  in  consequence 
of  which  they  have  a  disposition  to  reproduce,  when  again 
stimulated,  the  original  experience,  whether  an  idea  or  physi- 
ological reaction.  Hence  these  residues  are  called  uncon- 
scious "  residua  "  or  "  dispositions."  They  have  a  hypo- 
thetical existence  like  the  atoms  and  molecules  of  physics,  but 
upon  them  the  theory  of  memory  is  based.  They  may  be 
likened  to  the  impressions  left  in  the  wax  cylinder  or  the 
magnetization  of  the  wire  of  the  phonograph  by  the  spoken 
word.  A  complex  of  such  residua  is  an  "  unconscious 
complex." 

But  besides  mental  experiences  all  observation  and  ex- 
perimentation show  that  pure  physiological  reactions  asso- 
ciated with  a  given  mental  experience  are  conserved  as  a  part 
of  that  association.  The  ideas,  for  example,  belonging  to  a 
fright  complex  which  originally  were  accompanied  by  palpi- 
tation of  the  heart,  tremor,  perspiration,  muscular  weak- 
ness, etc.,  when  reproduced  in  memory  are  again  accom- 
panied by  all  these  physiological  reactions.  So  in  Pawlow's 


The  Psychological  Principles  and  Field  of  Psychotherapy  23 

j 

dogs  the  repeated  experiences  of  a  sensation  of  touch, 
accompanied  with  the  physiological  reactions  of  saliva, 
became  a  complex  which  was  conserved  and  reproduced  on 
subsequent  occasions.  The  nervous  system  faithfully  con- 
serves and  reproduces  its  experiences.  Conservation  is 
fundamental  for  education;  for  upon  it  the  law  of  linking 
of  complexes  depends.  It  is  obvious,  for  instance,  that  the 
education  of  coaptative  synergesis  of  muscular  movements 
for  purposeful  acts  would  be  impossible  unless  by  the  act 
of  experience  something  capable  of  reproduction  were  im- 
pressed upon  the  neurones.  Now  the  more  often  an  expe- 
rience is  repeated  and  the  stronger  its  emotional  tone,  the 
more  likely  it  is  to  be  conserved.  Thus  we  repeat  a  verse 
or  a  rule  of  grammar  until  we  know  it  by  heart;  or  we  repeat 
a  movement  until  it  becomes  automatic. 

But  without  repetition  the  elements  of  an  experience 
may  become  linked  and  conserved.  We  undergo  an  emo- 
tional experience  accompanied  by  various  bodily  reactions, 
as  in  a  railroad  accident,  or  we  experience  an  abhorrent  idea, 
or  one  of  apprehension,  or  repulsive  desire  — r  in  each  case 
the  nervous  organism  remembers  the  experience  and  upon 
proper  stimulus  can  reproduce  it.  The  emotional  tone 
seems  to  intensify  the  impression  on  the  brain  organization. 

Further,  on  the  principle  just  described  of  the  linking 
together  of  experiences  into  complexes,  or  associated  groups 
of  ideas,  feelings,  and  physiological  reactions,  it  is  evident  that 
large  unconscious  complexes,  representing  experiences,  may 
be  conserved  and  afterward  reproduced  as  a  whole  by  stimu- 
lation of  the  neuron  residua.  Observation  shows  that  this 
is  exactly  what  happens;  and  when  these  complexes  are  of 
an  unhealthy  kind  we  call  them  obsessions,  phobias,  etc., 
which  in  reality  are  nothing  but  experiences  faithfully  con- 
served as  residua  and  reproduced  from  time  to  time.  They 
may  also  be  called  association  psychoses  or  neuroses  on  the 
basis  of  their  mechanism. 


24  Psychotherapeutics 

Now  another  fact  which  has  been  proved  by  experi- 
mentation and  observation:  A  complex,  i.e.,  the  unconscious 
residua  of  a  complex,  may  be  almost  photographically  con- 
served notwithstanding  that  we  may  not  be  able  to  volun- 
tarily reproduce  it,  i.e.,  recall  the  original  experience.  It 
may  be  preserved  in  the  unconscious  neurons  and  be  made 
to  reproduce  itself  by  some  special  device.  E.g.,  a  child- 
hood experience  may  be  entirely  forgotten,  yet  that  it  may  be 
still  preserved  is  shown  by  the  fact  that  it  can  be  recalled  in 
even  all  its  minute  details  in  hypnosis,  dreams,  etc.  When 
recalled  in  dreams  it  often  takes  on  a  distorted  form  and, 
freed  from  a  true  appreciation  of  its  meaning,  it  awakens  the 
liveliest  and  often  terrifying  emotions.  This  latter  is  a 
matter  of  considerable  significance,  for  the  same  principle 
plays  a  part  in  hysterical  crises. 

Another  fact  of  observation  needs  to  be  grasped  in  all 
its  significance,  for  it  underlies  one  practical  method  of 
psychotherapy.  The  failure  to  appreciate  this  has  led  to 
misunderstandings  of  the  principle  of  hypnotic  suggestion 
and  indirectly  to  a  denial  that  such  suggestions  are  of  thera- 
peutic value,  while  at  the  same  time  it  is  admitted  that 
waking  suggestion  is  efficacious.  The  fact  is  this :  It  makes 
no  difference  in  what  state  complexes  are  formed,  whether  in 
every  day  life,  in  sleep,  trance,  dissociated  personality,  sub- 
conscious states  or  hypnosis,  they  are  or  may  be  equally 
firmly  organized  and  conserved,  and  they  are  conserved 
whether  we  can  voluntarily  recall  the  experiences  or  not. 
Whether  they  are  to  become  organized  depends  upon  the 
mode  and  conditions  under  which  the  impression  is  made 
upon  the  mind  or  nervous  system,  but  once  organized  they 
are  conserved  and  become  a  part  of  our  personality.  We 
cannot  get  rid  of  them  unless  they  are  effaced  by  the  corrod- 
ing action  of  time  or  disease.  We  are  accustomed  to  think 
of  experiences  belonging  to  such  states  as  not  belonging  to 
ourselves.  This  is  a  mistake.  All  experiences,  however, 
and  wherever  formed,  if  conserved,  are  a  part  of  our- 


The  Psychological  Principles  and  Field  of  Psychotherapy    25 

selves  and  belong  to  the  storehouse  of  our  knowledge,  though 
we  may  or  may  not  afterwards  draw  upon  that  storehouse  in 
practical  life.  We  know  that  dreams  which  are  not  even 
remembered  may  be  not  only  conserved  but  may  influence 
the  personality  during  quite  long  periods  of  time  for  good  or 
for  ill.  I  have  now  a  case  under  observation  where  an  idea 
complex  occurring  in  a  dream  persisted  after  waking  as  an 
obsession,  and  has  continued  as  such  to  the  present  time, 
a  period  of  twelve  years. 

If  a  complex  then  of  ideas,  which  make  up  points  of 
view,  attitudes  of  mind,  beliefs,  hopes,  and  aspirations,  is 
once  firmly  formed  and  organized  in  hypnosis,  it  remains 
as  a  part  of  our  personality. 

Further,  experimentation  and  clinical  observation  have 
conclusively  proven  that  a  complex  of  ideas  formed  in  hyp- 
nosis, whether  remembered  when  the  personality  is  awake 
or  not,  can  affect,  modify,  or  determine  the  ideas,  beliefs, 
feelings,  emotions,  etc.,  of  the  individual.  The  elements  of 
the  hypnotic  complex  enter  the  stream  of  thought  of  every- 
day life  and  modify  it.  Whether  it  will  do  so  or  not  depends 
on  various  conditions.  How  it  does  so  is  another  question 
which  we  cannot  enter  into  here.  That  it  may  do  so  is  a 
fact  which  can  be  proven  as  often  as  we  wish  to  try  the  ex- 
periment. If  this  is  so  when  there  is  complete  amnesia 
after  waking  from  hypnosis  it  can  be  understood  how  much 
more  easily  it  may  be  the  case  when,  as  happens  in  nine 
tenths  of  such  procedures,  hypnosis  is  little  more  than  a 
state  of  relaxation  and  abstraction  and  is  not  followed  by 
amnesia,  but,  on  the  contrary,  the  whole  hypnotic  experience, 
all  the  ideas  of  the  complex  which  were  therein  formed  are 
remembered  by  the  subject.  When  it  is  remembered  that 
in  hypnosis  there  is  increased  suggestibility,  and  that  there 
may  be  induced  a  dissociation  of  all  ideas  which  clash  with 
and  antagonize  the  suggested  ideas,  thereby  allowing  a  new 
synthesis  to  be  formed,  we  can  see  what  a  powerful  influence 
can  be  exercised  on  the  personality  by  this  procedure. 


26  Psychotherapeutics 

3.      DISSOCIATION 

The  next  principle  to  which  I  would  call  your  attention 
is  one  to  which  I  have  already  referred  above,  namely  disso- 
ciation. It  is  a  general  principle  governing  the  normal 
psycho-nervous  mechanism  and  therefore  in  a  highly  marked 
form  only  is  pathological.  A  characteristic  type  is  functional 
amnesia  by  which  an  epoch  or  a  long  period  of  time  is  blotted 
out  of  the  memory.  You  will  recall  cases  where  following 
an  emotional  trauma  the  preceding  hours  or  days  or  months 
are  forgotten.  The  experiences  of  this  time  cannot  be  re- 
called as  memories;  but  they  are  still  preserved  as  brain 
residua,  for  they  can  be  reproduced  by  artificial  means 
through  hypnosis  and  other  methods.  The  amnesia  for  the 
hypnotic  state  and  dreams  after  waking  is  also  due  to  the 
same  principle,  as  is  also  that  following  numerous  other  states 
which  I  cannot  spare  the  time  to  mention  here.  What  has 
happened  in  such  conditions  is  a  dissociation  between  the 
systems  of  brain  residua  which  correspond  to  the  psycho- 
logical experiences.  There  is  an  inability  to  synthesize 
these  systems  into  one  personality  and  hence  the  amnesia. 

Amnesia,  of  course,  as  a  technical  term,  includes  only 
ideas,  but  dissociated  systems  or  complexes  may  include 
motor  and  sensory  functions,  and  these  we  meet  with  as 
paralyses  and  anesthesias  as  observed  in  hysteria.  That 
such  dissociations  are  purely  functional  is  shown  by  the  fact 
that  they  can  be  produced  by  suggestion  and  removed 
(synthesis)  by  suggestion.  When,  as  sometimes  happens, 
a  single  symptom  like  paralysis  and  anesthesia  cannot  be 
removed  by  suggestion,  if  the  whole  dissociated  system  to 
which  this  symptom  belongs  is  synthesized  by  suggestion  the 
symptom,  paralysis  or  anesthesia,  disappears.  Here  again 
we  have  a  fact  important  for  psychotherapeutics, —  the  fact 
that  we  can  produce  dissociation  and  synthesis  by  sugges- 
tion,—  for  if,  as  experimental  investigation  has  shown,  the 


The  Psychological  Principles  and  Field  of  Psychotherapy  27 

basis  of  certain  psycho-pathological  conditions  like  hysteria 
is  dissociation,  we  have  a  means  at  our  command  which  may 
be  used  for  the  resynthesizing  of  the  personality,  i.e.,  the 
restoration  of  the  normal  individual.  It  is  important  not 
to  lose  sight  of  the  fact  that  dissociation  is  a  function  of  the 
normal  mechanism  of  the  mind  and  nervous  system,  and 
is  made  use  of  in  normal  life  for  the  adaptation  of  the  indi- 
vidual to  the  constant  and  ceaseless  changes  of  the  environ- 
ment. It  is  the  enormous  exaggeration  and  perversion  of 
this  dissociating  mechanism  that  constitutes  abnormality. 
A  suggested  idea  simply  stimulates  and  makes  use  of  the 
normal  mechanism,  otherwise  it  can  have  no  effect. 

Among  the  normal  phenomena  of  dissociation  are  to  be 
reckoned  temporary  and  some  permanent  forms  of  forget- 
fulness,  the  limitation  of  the  field  of  consciousness  in  absent- 
mindedness,  moods,  anger,  and  other  strong  emotional  states 
and  sleep.  Amongst  the  artificial  and  pathological  condi- 
tions characterizing  largely  or  chiefly  the  dissociations  are 
hypnotic  and  hypnoidal  states;  suggested  and  hysterical 
amnesia,  paralyses,  contractures,  anesthesia?,  etc.;  somnam- 
bulism, trance,  psycholeptic  attacks,  etc. 

Emotion,  again,  is  a  powerful  factor  in  producing  dis- 
sociation as  well  as  the  linking  and  conservation  of  complexes. 

In  the  so-called  neurasthenic  state  and  hysteria  disso- 
ciation plays  a  very  important  part.  All  cases  of  hysteria 
and  many  of  neurasthenia  are,  as  I  see  the  matter,  cases  of 
dissociated  personality,*  but  it  would  carry  us  too  far  from  our 
main  subject  to  discuss  this  aspect  of  the  matter  at  this  time. 

Subconscious  Ideas.  There  are  certain  important  phe- 
nomena of  dissociation  and  conservation  that  ought  not  to  be 
omitted,  considering  the  important  part  which  they  sometimes 
play,  and  the  large  amount  of  attention  which  they  have 
received. 

*  Morton  Prince:  Hysteria  from  the  Point  of  View  of  Dissociated 
Personality,  JOURNAL  OF  ABNORMAL  PSYCHOLOGY,  October,  1906, 


28  Psychotherapeuttcs 

When  the  conserved  residua  of  an  unconscious  complex 
are  stimulated,  this  complex  becomes  a  conscious  memory  of 
which  we  are  aware,  but  sometimes  something  else  happens— 
it  becomes  a  conscious  memory  of  which  we  are  not  aware. 
Ideas  are  awakened,  but  we  are  not  aware  of  them.  These 
are  what  are  called  subconscious,  or  better,  co-conscious 
ideas,  which  means  ideas  dissociated  from,  split  off  from  the 
main  consciousness.  This  is  an  interpretation  of  certain 
phenomena  belonging  to  abnormal  psychology  which  would 
carry  us  too  far  afield  to  consider  here;  but  the  evidence  is 
so  strong  that  it  is  impossible  to  resist  the  conclusion.  Now 
when  this  is  the  case  such  ideas  often  resemble  dreams  - 
fixed  dreams.  The  ideas,  like  dreams  freed  from  the  control 
of  the  personal  consciousness  which  has  no  appreciation  of 
their  existence  or  meaning,  take  on  a  distorted  form,  and 
when  accompanied  by  emotions  acquire  all  the  characteristics 
of  nightmares  —  subconscious  nightmares  they  may  be 
called.  That  they  should  produce  psychological  and  mental 
disturbances  is  not  to  be  wondered  at.  This  is  what  is  some- 
times found  in  hysteria  when  they  produce  the  so-called 
hysterical  crises.  To  get  rid  of  such  subconscious  night- 
mares must  plainly  be  an  object  for  psychotherapy.  A 
simple  type  of  the  dissociated  co-conscious  idea  is  found  in 
hysterical  anesthesia.  Here  there  is  no  absolute  anesthesia. 
The  lost  tactile  sensations  are  only  split  off  from  the  personal 
consciousness  and,  although  the  patient  is  unaware  of  them, 
they  are  preserved  as  co-conscious  perceptions  or  tactual 
ideas.  To  resynthesize  these  perceptions  with  the  personal 
consciousness  is  to  make  the  patient  aware  of  them  and 
remove  the  anesthesia. 

I  pass  over  as  a  controversial  matter  the  mechanism  by 
which  co-conscious  ideas  are  dissociated  from  the  main 
content  of  the  personal  consciousness,  i.e.,  by  which  the 
person  becomes  no  longer  aware  of  them.  Differing  views 
are  maintained.  By  some  it  is  held  that  in  disease,  as  in 


The  Psychological  Principles  and  Field  of  Psychotherapy  29 

hysteria,  the  splitting  of  the  mind  is  due  to  fatigue  and 
emotional  trauma;  by  others  that  it  is  due  to  the  direct  voli- 
tional repression,  or  the  pushing  out  of  consciousness  of 
ideas  which  are  unacceptable  to  the  individual.  But  which- 
ever mechanism  is  the  correct  one,  whether  dissociation  is 
brought  about  by  voluntarily  repressing  painful  or  unac- 
ceptable ideas  or  whether  by  an  over-intense  stimulus  from 
an  emotional  trauma  to  which  the  individual  is  not  adapted, 
or  by  fatigue,  in  any  case  the  pathological  dissociation  is  but 
an  exaggeration  or  perversion  of  a  normal  dissociating 
mechanism.  That  it  still  remains  functional  is  shown  by 
the  fact  that  a  functional  stimulus  (suggestion)  is  capable 
of  producing  it  and  removing  it.  We  have  here  a  type  of 
functional  disease  which  is  somewhat  different  in  form  from 
that  which  results  from  the  educational  process,  although 
this  may  come  later  into  play  in  evolving  subsidiary  symp- 
toms. I  hardly  need  point  out  that  the  secondary  effects  of 
dissociation  — hysterical  stigmata,  etc. —  are  but  the  products 
of  the  normal  functioning  of  the  mutilated  and  dissociated 
fragments  of  the  personality. 


30  Psychotherapeutics 

4.      AUTOMATISM 

In  the  mechanism  of  normal  psychic  life,  automatism 
plays  a  much  larger  part  than  is  generally  realized.  This 
principle  tends  to  the  economy  of  effort.  We  see  it  in  habit 
actions  and  absent-minded  acts  when  our  attention  is 
directed  to  some  other  train  of  thought  than  that  engaged  in 
the  actions.  Even  language  symbols  tend  to  become  asso- 
ciated into  set  phrases  and  formulas,  which  tend  to  become 
automatic  and  labor-saving  devices  for  the  expression  of 
thought.  In  expletives  and  explosive  phrases  which  almost 
unconsciously  give  vent  to  our  feelings  we  easily  recognize 
these  language  automatisms.  Less  conspicuous  as  auto- 
matisms is  the  activity  of  complexes  of  ideas,  however 
formed,  which  function  more  or  less  automatically  as  a 
group  and  determine  the  direction  of  our  thought  and  its 
content.  The  association  experiments  have  done  much 
to  bring  to  light  this  automatic  activity  of  complexes,  and  we 
are  under  deep  obligations  to  Freud,  Bleuler,  and  Jung 
for  having  directed  our  attention  to  this  principle  and  em- 
phasized these  particular  facts.  In  pathological  fixed  ideas 
which  rush  into  consciousness  unbidden  and  undesired  we 
can  clearly  see  this  automatic  activity.  So  in  establishing 
fixed  habits  of  thought,  in  forming  deeply  rooted  ideas  and 
points  of  view,  beliefs,  etc.,  we  form  complexes  which  are 
capable  of  more  or  less  autonomous  action. 

When  psychological  and  physiological  processes  become 
dissociated,  and  thereby  freed  from  the  inhibitory  control 
of  the  personal  consciousness,  automatism  is  observed  in  its 
most  highly  developed  form.  The  split  off  groups  of  psycho- 
logical or  physiological  elements  acquire  what  may  be  called 
a  hyper-excitability  and  are  capable  of  extremely  independent 
functioning.  The  manifestations  may  be  in  the  form  of 
subconscious  ideas,  hallucinations  (sensory  automatisms), 
tics,  spasms,  convulsions,  contractures  (motor  automatisms), 


The  Psychological  Principles  and  Field  of  Psychotherapy  3 1 

etc.  Primarily  such  pathological  phenomena  depend  upon 
dissociation  of  the  nervous  organism  and  the  stimulus  by  some 
excitation  from  within  or  without  of  the  nervous  mechanism 
involved.  With  reassociation  and  cessation  of  stimulus  the 
automatisms  logically  cease.  The  aim  of  psychotherapy, 
therefore,  must  plainly  be  to  reassociate  the  split  up  person- 
ality, and  to  form  such  healthy  complexes  of  ideas  as  will 
not  stimulate  the  undesired  complexes,  but  by  their  automatic 
activity  will  contribute  to  the  well-being  of  the  individual 
and  adapt  him  to  his  environment. 


32  Psychotherapeutics 

5.       EMOTIONAL  ENERGY 

It  is  a  fact  of  observation  that  intense  sthenic  emotions 
and  feelings  are  accompanied  by  an  increase  of  the  vital 
functions  while,  per  contra,  certain  depressive  emotions  and 
feelings  are  accompanied  by  a  decrease  of  the  vital  functions. 
Further,  it  is  generally  recognized  by  psychologists  that  most, 
if  not  all,  ideas  have  a  feeling  tone  attached  to  them.  Con- 
sequently if  certain  complexes  of  ideas  which  have  intense 
sthenic  feeling  tones  are  brought  into  the  personal  con- 
sciousness there  is  awakened  a  state  of  energy,  a  feeling  of 
wellbeing  and  capacity,  and  an  invigoration  of  the  whole 
organism.  If,  on  the  other  hand,  complexes  of  ideas  which 
have  depressive  or  distressing  feeling  tones  are  brought  into 
the  personal  consciousness,  the  contrary  effect  is  produced. 
Stating  the  same  fact  in  another  way,  exalting  emotions  have 
an  intense  synthesizing  effect  while  depressing  emotions  have 
a  disintegrating  effect.  This  last  we  see  exemplified  in  emo- 
tional trauma  (traumatic  neuroses)  where  sometimes  a  com- 
plete dissociation  or  splitting  of  the  personality  occurs  being 
manifested  by  altered  personality,  anesthesia,  paralysis,  etc. 
Every  one  who  has  studied  the  hypnotic  states  must  have 
observed  these  phenomena  experimentally  produced.  With 
the  inrushing  of  depressive  memories  or  ideas  whether 
originating  autochthonously  in  the  associations  of  the  mind 
of  the  patient,  or  accidentally  or  intentionally  suggested  by 
the  experimenter,  there  is  suddenly  developed  a  condition 
of  fatigue,  illbeing,  and  disintegration,  followed  after 
waking  by  a  return  or  accentuation  of  all  the  neurasthenic 
symptoms.  If  on  the  other  hand  exalting  ideas  and  mem- 
ories are  introduced  and  brought  into  the  limelight  of  attention 
there  is  almost  a  magical  reversal  of  the  process.  The  pa- 
tient feels  strong  and  energetic,  the  neurasthenic  symptoms 
disappear,  and  he  exhibits  a  capacity  for  sustained  effort. 
He  becomes  revitalized  so  to  speak.  This,  I  believe,  is  the 


The  Psychological  Principles  and  Field  of  Psychotherapy  33 

secret  of  those  changes  of  character  and  physical  capacity 
which  William  James  has  so  brilliantly  illuminated  in  his 
essay  on  the  "  Energies  of  Men."  Complexes  of  ideas  ac- 
companied by  strong  feeling  tones  which  have  long  lain  fal- 
low are  brought  out  of  their  dormant  abode  and  made  to 
become  a  part  of  the  working  force  of  the  mental  factory. 

In  this  principle,  then,  we  see  a  mechanism  which  tends 
to  the  development  of  the  neuroses  and  psychoses  on  the  one 
hand,  and  to  states  of  invigorating  health  on  the  other, 
according  as  whether  disintegrating  or  synthesizing  emotions 
and  feelings  are  brought  into  the  conscious  field  of  the  indi- 
vidual. In  the  hypnoidal  state  of  Sidis  and  in  hypnosis 
it  is  particularly  easy  to  bring  out  of  the  dormant  conscious- 
ness into  this  active  central  field  memories  and  ideas  which 
have  been  pushed  aside  or  upon  which  the  individual  has 
lost  his  grip  by  reason  of  their  having  become  dissociated  by 
fatigue,  friction  with  the  environment,  or  by  other  disintegrat- 
ing factors.  It  is  thus  easy  to  modify  the  personality  at  will 
by  measures  which  make  use  of  this  principle.  The  trans- 
formation effected  by  the  development  of  energy  in  this 
way  is  often  most  striking  and  is  often  commented  upon  by 
the  patient.  On  the  other  hand,  I  have  observed  that  when 
for  any  reason  depressive  memories  and  such  idea-com- 
plexes enter  and  remain  in  the  mind  of  the  hypnotized 
subject,  no  matter  what  suggestions  are  given,  the  patient 
on  waking  becomes  or  remains  correspondingly  depressed 
and  neurasthenic. 

I  have  thus  far  briefly  formulated  the  main  psychological 
principles  upon  which  psychotherapy  rests.  The  point  I 
wish  to  bring  out  into  strong  relief  is  that  these  principles 
or  tendencies  govern  the  normal  functioning  of  the  psycho- 
nervous  system,  and  that  it  is  the  perversion  of  these  ten- 
dencies which  constitute  functional  disease;  that  is  to  say 
reactions  which  misadapt  the  individual  to  his  environment 
and  which  result  from  normal  functioning  under  conditions 


34  Psychotherapeutics 

to  which  the  individual  is  not  adapted.  Functional  disease 
is  therefore  a  process  of  perverted  functioning.  Conversely 
psychotherapy  makes  use  of  these  same  principles  or  ten- 
dencies to  re-adapt  the  individual  to  his  environment,  to  re- 
educate him  to  healthy  reactions. 

Psychotherapy  simply  makes  use  of  the  normal 
mechanism  of  the  mind  and  body,  of  the  physiological 
machinery  to  bring  about  a  restitution  of  the  disordered 
functions  and  restore  the  individual  to  health.  Thus  sug- 
gestion can  only  act  by  stimulating  the  physiological  me- 
chanism, it  can  only  make  use  of  machinery  already  provided; 
it  cannot  create  anything  anew,  do  anything  that  is  not  in 
accord  with  the  laws  of  the  nervous  system.  As  a  method 
psychotherapy  is  comparable  in  every  way  to  what  is  now 
known  as  physiological  therapeutics  which  has  taken  such 
an  important  place  in  modern  treatment  in  internal  medicine. 

I  fear  my  exposition  has  been  too  brief  to  enable  these 
principles  to  be  clearly  grasped  by  those  who  have  not 
systematically  studied  and  observed  the  phenomena  of  ab- 
normal psychology.  The  field  of  investigation  is  a  wide 
one,  and  to  thoroughly  comprehend  the  meaning  of  the  facts 
that  are  to  be  observed  one  must  make  himself  familiar  with 
them  at  first  hand  as  one  would  expect  to  do  in  bacteriology 
if  he  would  understand  the  principles  of  infectious  disease 
and  immunity. 

The  psychological  principles  I  have  attempted  to  elu- 
cidate may  be  summed  up  as:  First,  Complex  formation; 
second,  Conservatism;  third,  Dissociation;  fourth,  Automa- 
tism; fifth,  Emotional  Energy. 

Each  of  these  principles  is  made  use  of  by  psychotherapy 
in  greater  or  less  degree  according  to  the  conditions  pre- 
sented. If  we  are  dealing  with  a  simple  psycho-neurosis  of 
the  neurasthenic  type  where  the  disturbance  can  be  traced 
to  the  first  class  of  facts  I  have  mentioned, — i.e.,  to  unhealthy 
ideas,  self-examination,  worry,  erroneous  beliefs  in  and 


The  Psychological  Principles  and  Field  of  Psychotherapy  35 

apprehension  of  disease  with  the  depressive  emotional  tones 
that  go  with  such  states,  to  habits  of  introspection  and  con- 
centration of  the  mind  on  the  functions  of  the  body,  etc., — 
the  main  principle  to  be  made  use  of  is  the  organization  and 
substitution  of  healthy  complexes  in  place  of  the  unhealthy 
ones.  This  is  not  a  simple  procedure,  but  an  art.  It  often 
requires  all  the  skill  which  can  be  acquired  from  a  knowledge 
of  human  nature,  of  life,  the  data  of  abnormal  psychology, 
and,  above  all,  from  a  recognition  of  the  principles  above 
formulated.  The  point  of  view,  the  attitude  of  mind,  the 
beliefs,  the  habits  of  thought,  must  be  modified  by  the  intro- 
duction of  new  points  of  view,  of  data  previously  unknown 
to  the  patient  and  drawn  from  the  wider  experience  of  the 
physician;  by  instruction  in  the  meaning  of  symptoms  and 
in  their  organization  and  causes;  by  the  suggestion  of  ex- 
pectations that  justly  may  be  fulfilled;  of  ambitions  that 
ought  rightfully  to  be  entertained;  of  duties  to  be  assumed 
but  too  long  neglected;  of  confidence  and  hope;  and,  above 
all,  by  the  suggestion  of  the  emotion  and  joy  that  go  with 
success  and  a  roseate  vista  of  a  new  life.  There  is  no  fact 
of  life  that  does  not  have  more  than  one  aspect,  no  conduct 
that  does  not  have  more  than  one  interpretation,  no  judg- 
ment that  does  not  have  an  alternative,  no  conduct  that  does 
not  have  more  than  one  relation.  Thus  the  old  systems  of 
ideas  carrying  with  them  apprehensions,  anxieties,  and  de- 
pressive emotions  are  modified  by  being  interwoven  with 
new  ones,  and  new  systems  of  ideas  or  complexes  are  art- 
fully created  and  substituted  for  the  old.  These  systems 
should  be  such  as  will  stimulate  healthy  reactions  of  the 
body  in  place  of  the  unhealthy  perverted  reactions. 

Finally  the  whole  complex,  by  repetition,  emphasis,  and 
the  stimulus  of  emotion,  is  firmly  linked  and  organized  until 
it  becomes  conserved  as  unconscious  brain  residua  and  a 
part  of  the  individual's  personality.  If  thus  conserved  it  will 
be  reproduced  whenever  stimulated.  To  be  effective  ideas 


36  Psychotherapeutics 

must  be  fixed,  conserved,  else  they  become  the  sport  of  every 
passing  thought  and  feeling.  But  for  this  they  must  be  ac- 
cepted and  to  be  accepted  they  must  be  the  truth,  as  they 
should  be  on  ethical  and  rationalistic  grounds.  Every 
person  can  bear  the  truth  but  it  should  be  the  whole  truth 
and  not  half  the  truth  or  only  one  aspect  of  the  truth  or  the 
truth  that  allows  erroneous  interpretations.  All  this  thera- 
peutic procedure  of  course  means  the  education,  or  perhaps 
better,  the  re-education  of  the  patient.  It  is  the  same 
process  that  in  Pawlow's  dogs  led  to  the  secretion  of  gastric 
juice  and  saliva  by  educated  reactions  to  the  environment,  and 
in  hay  fever  neurotics  to  the  creation  of  the  coryza  complex 
as  a  perverted  reaction  to  mental  and  physical  stimuli.  Only 
the  therapeutic  process  is  the  association  through  education 
of  healthy  ideas  and  stimuli  that  adapt  the  individual  to  his 
environment. 


The  Psychological  Principles  and  Field  of  Psychotherapy  37 


This  is  a  much  discussed  question.  One  meets  often 
with  assertions  rather  than  arguments  which  are  made  with 
a  warmth  and  acrimony  of  feeling  that  betokens  prejudice 
rather  than  a  masterly  knowledge  of  the  subject.  From 
the  point  of  view  of  formation  of  complexes  it  must  be  evi- 
dent, if  the  psychological  principles  which  I  have  set  forth 
are  well  grounded,  that  it  matters  little  in  what  state  these 
therapeutic  systems  of  ideas  are  formed,  whether  in  hypnosis 
or  in  the  waking  state.  When  once  formed  they  become  a 
part  of  our  personality  and  take  part  in  swelling,  modifying, 
and  directing  the  stream  of  mental  life.  This  can  readily  be 
apprehended  when  it  is  remembered  that  in  ninety  per  cent 
of  cases  so-called  hypnosis  is  little  more,  as  I  have  already 
said,  than  a  condition  of  abstraction  with  relaxation  in  which 
suggestibility  is  heightened.  On  returning  to  the  full  waking 
state  there  is  complete  memory  of  the  whole  hypnotic  episode, 
so  that  the  suggested  ideas  are  accurately  remembered.  As 
a  matter  of  fact  hypnosis  is  only  necessary  in  a  small  minority 
of  cases.  In  obstinate  cases  hypnosis  has  the  advantage  that, 
suggestibility  being  increased  and  antagonistic  ideas  being 
dissociated  or  inhibited,  the  new  ideas  are  more  readily 
accepted  and  the  complexes  more  easily  and  firmly  organized. 
Then  after  waking  the  patient  who  remembers  the  suggested 
complexes  finds  that  his  whole  state  of  mind  is  modified. 

But  even  when  amnesia  follows  after  waking  the  result 
is  the  same.  Then*  on  examination  we  find,  however 
complicated,  that  the  suggested  ideas  and  emotions  weave 
themselves  into  the  thoughts  of  the  conscious  individual  and 
modify  them;  or  the  emotions,  alone,  may  intrude  them- 
selves and  determine  the  mood  and  the  whole  psychic  con- 

*Cf.  The  Unconscious,  JOURNAL  OF  ABNORMAL  PSYCHOLOGY,  April — 
May,  1909. 


38  Psychotherapeutics 

tent.  To  take  an  actual  case,  I  suggest  to  B.  C.  A.,  in 
hypnosis,  ideas  of  wellbeing,  of  recovery  from  her  infirmity; 
I  picture  a  future  roseate  with  hope,  stimulate  her  ambitions 
with  suggestions  of  duties  to  be  performed,  deeds  to  be  ac- 
complished. With  all  this  there  goes  an  emotional  tone  of 
exaltation  which  takes  the  place  of  the  depression  and  of  the 
sense  of  failure  previously  present.  This  emotional  tone 
gives  increased  energy  to  her  organization,  revitalizing,  as  it 
were,  her  psycho-physiological  processes.  The  whole  I 
weave  artfully  and  designedly  into  a  complex.  Whatever 
neurotic  symptoms  were  previously  present,  I  do  not  allow 
to  enter  this  complex.  Indeed,  the  complex  is  such  that 
they  are  incompatible  with  it.  The  headache,  nausea,  and 
other  bodily  discomforts,  pure  functional  disturbances  in 
this  instance,  are  dissociated  and  cease  to  torment.  After 
"  waking,"  there  is  complete  amnesia  for  the  complex.  Yet 
it  is  still  organized,  for  it  can  be  recovered  again  in  hypnosis. 
It  is  simply  dormant.  But  the  emotional  tone  still  persists 
after  waking  and  invades  the  personal  synthesis  which  takes 
on  a  correspondingly  ecstatic  tone.  The  aspect  of  her  en- 
vironment, her  conception  of  her  relation  to  the  world,  and 
her  past,  present,  and  future  mental  life  have  become  colored, 
so  to  speak,  by  the  new  feeling,  as  if  under  a  new  light.  But 
more  than  this,  new  syntheses  have  been  formed  with  new 
tones.  If  we  probe  deep  enough  we  find  that  many  ideas 
of  the  dormant  complex  have,  through  association  with  the 
environment  (point  de  repere\  become  interwoven  with  those 
of  the  previous  personal  consciousness  and  given  all  a  new 
meaning.  A  moment  ago  [her  view  was  that]  she  was  an 
invalid,  incapacitated,  exiled  from  her  social  and  family 
life,  etc.  What  was  there  to  look  forward  to  ?  Now:  What 
of  that  ?  She  is  infinitely  better;  what  a  tremendous  gain; 
at  such  a  rate  of  progress  in  a  short  time  a  new  life  will  be 
open  to  her,  etc., — a  radically  new  point  of  view.  Now,  too, 
she  feels  buoyant  with  health  and  energy,  ready  to  start  afresh 


The  Psychological  Principles  and  Field  of  Psychotherapy  39 

on  her  crusade  for  health  and  life.  Her  neurotic  symptoms 
have  vanished.  Such  is  the  change  that  she  gratefully 
speaks  of  it  as  the  work  of  a  wizard.  But  the  mechanism 
of  the  transformation  is  simple  enough.  The  exaltation, 
artificially  suggested  in  hypnosis,  persists,  altering  the  trend 
of  her  ideas  and  giving  new  energy.  The  perceptions  of 
her  environment,  cognition  of  herself,  etc.,  have  entered  into 
new  syntheses  which  the  introduction  of  new  ideas,  new 
points  of  view  have  developed;  thus  the  content  of  her  ideas 
has  taken  a  definite  precise  shape.  Whence  came  these  new 
ideas  ?  They  seem  to  her  to  have  come  miraculously,  for 
she  has  forgotten  the  hypnotic  complex.  But  forgetting  an 
experience  is  not  equivalent  to  its  not  having  happened  or 
to  that  experience  not  having  been  a  part  of  our  own  psychic 
life.  The  hypnotic  consciousness  remains  a  part  of  one's 
self  (as  a  psychological  complex),  however  absolutely  we  have 
lost  awareness  of  it.  Its  experiences  become  fixed  though 
dormant,  just  as  do  the  experiences  of  our  personal  con- 
scious life.  .  .  .  The  mechanism  is  the  same. 

The  following  letter  from  this  patient,  received  by 
chance  after  these  paragraphs  were  written,  well  expresses 
the  psychological  conditions  following  hypnotic  suggestion. 

"  Something  has  happened  to  me  —  I  have  a  new  point 
of  view.  I  don't  know  what  has  changed  me  so  all  at  once, 
but  it  is  as  if  scales  had  fallen  from  my  eyes;  I  see  things 

differently.     That    affair    at    L was    nothing    to    be 

ashamed  of,  Dr.  Prince.  I  showed  none  of  the  common 
sense  which  I  really  possess;  I  regret  it  bitterly;  but  I  was 
not  myself  and  even  as  [it  was]  I  did  nothing  to  be  ashamed 
of — quite  the  contrary,  indeed.  .  .  Anyway,  for  some 
reason  —  I  don't  know  why,  but  perhaps  you  do  —  I  have 
regained  my  own  self-respect  and  find  to  my  amazement 
that  I  need  never  have  lost  it.  You  know  what  I  was  a  year 
ago  — you  know  what  I  am  now;  not  much  to  be  proud  of, 
perhaps,  but  I  am  the  work  of  your  hands  and  a  great  im- 


40  Psychotherapeutics 

provement  on  [my  poor  old  self].  I  owe  you  what  is  worth 
far  more  than  life  itself  .  .  .  namely,  the  desire  to  live.  You 
have  given  me  life  and  you  have  given  me  something  to  fill 
it  with  ...  I  feel  more  like  myself  than  for  a  long  time.  I 
am  '  my  own  man  again  '  so  to  say,  and  if  you  keep  me  and 
help  me  a  little  longer  I  shall  be  well." 

When  dissociation  exists  it  becomes  self-evident  that  a 
restoration  of  the  healthy  organization  can  only  be  attained 
by  a  reassociation  of  the  dissociated  functions.  It  is  obvious 
that  subconscious  ideas,  when  disturbing,  need  either  to  be  so 
modified  that  they  cease  to  function,  i.e.,  to  be  subconscious 
and  dissociated,  or  to  be  reintegrated  with  the  personal  con- 
sciousness, i.e.,  brought  into  the  full  light  of  conscious  knowl- 
edge, and  thereby  realized  in  all  their  meaning,  rearranged 
and  modified;  just  as  a  dream  becomes  modified  and  loses  its 
psychological  meaning  and  its  physiological  effects  after 
waking  with  a  full  awareness  of  its  falsity.  Disintegrated 
personality  needs  to  be  reassociated  into  a  unified  complete 
personality,  with  full  possession  of  its  faculties  and  functions, 
etc.  There  are  many  empirical  ways  of  doing  this,  physical 
and  psychological,  but  amongst  the  methods  experience  has 
shown  that  there  are  several  psychological  procedures  which 
are  rational  and  prove  efficacious  when  physical  and  em- 
pirical methods  fail.  So-called  psycho-analysis,  suggestion 
in  the  waking  state  and  abstraction,  in  so-called  hypnoidal 
states  and  hypnosis,  mental  and  physical  hygiene,  all  have 
proved  to  be  efficient  in  bringing  about  a  reintegration  of 
dissociated  functions.  But  all  these  methods  are  only 
different  forms  of  education. 

The  principle  of  dissociation  and  association  is  exempli- 
fied by  the  process  of  hypnotizing  and  awaking  an  individual. 
Hypnosis  is  dissociation;  in  awaking  a  person  what  we  do  is 
to  re-synthesize  the  personality  and  to  restore  the  normally 
functioning  organism. 


The  Psychological  Principles  and  Field  of  Psychotherapy  41 

Finally  I  would  point  out  that  a  prerequisite  for  such 
psychotherapeutic  measures  is  a  preliminary  painstaking 
and  exhaustive  analysis  of  the  symptoms,  of  the  genesis  of  the 
psychosis,  of  the  logical  relation  of  the  symptoms  to  each 
other  and  to  mental  and  external  causes,  of  the  pathology 
of  the  symptoms  and  their  significance;  what  are  due  to 
auto-suggestion,  what  to  habit  or  education,  what  to  fatigue, 
what  to  true  organic  disease —  in  short  the  complete  meaning 
or  philosophy  of  the  disease  must  be  determined.  If,  as  is 
often  the  case,  incidents  in  which  the  psychosis  developed 
or  which  are  the  subconscious  cause  of  repeated  attacks  are 
forgotten,  the  memories  of  these  should  be  revived  by  one  or 
the  other  of  various  technical  methods  of  psycho-analysis. 
Only  through  a  knowledge  gained  in  this  way  in  each  indi- 
vidual case  can  a  rational  psychotherapy  be  undertaken. 
After  such  an  analysis  it  is  generally  surprising  to  find  that 
what  at  first  seemed  a  mere  chaos  of  unrelated  symptoms 
will  turn  out  to  be  governed  by  law  and  order. 


42  Psychotherapeutics 

HYSTERIA 

When  we  come  to  deal  with  the  more  profound  psycho- 
neurotic  states,  those  of  the  severer  hysterias,  a  somewhat 
different  therapeutic  procedure  is  usually  required.  Here 
we  have  to  do  with  dissociations,  often  of  a  profound  type, 
with  paralysis,  anesthesia,  alterations  of  personality  and  sub- 
conscious ideas  of  which  the  patient  is  unaware,  or  uncon- 
scious automatisms  freed  from  the  inhibitions  of  a  fully 
synthesized  personality.  For  psychotherapy  reassociation 
of  the  dissociated  functions  is  the  essential  principle,  although 
again  the  formation  of  new  healthy  complexes  is  necessary 
to  maintain  the  association.  Our  ingenuity  is  often  taxed  to 
the  utmost  in  devising  methods  to  reintegrate  the  psycho- 
physiological  personality.  Various  technical  devices  can 
be  made  use  of.  I  cannot  go  into  this  here,  as  I  am  only 
dealing  with  principles.  Suffice  it  to  say  that  sometimes 
reintegration  can  be  formed  in  a  special  state  of  hypnosis; 
sometimes  by  suggestion  in  hypnosis  or  to  the  waking  person- 
ality; sometimes  by  recalling  to  the  full  light  of  the  waking 
consciousness  the  subconscious  ideas  or  "  dreams  "  ;  some- 
times by  recalling  them  to  the  full  light  of  the  hypnotic  con- 
sciousness, etc.  By  doing  this  the  subconscious  "  dream  " 
or  fixed  idea  —  generally  a  memory  of  some  emotional 
incident  —  becomes  fully  recognized  as  to  its  meaning  and 
character,  and  thereby  interwoven  with  the  logical  processes 
of  waking  thought;  in  other  words,  synthesized  into  a  new, 
healthy  complex.  We  see  the  same  principle  when,  on 
waking  from  a  nightmare,  not  only  the  dream  but  the  realiza- 
tion that  it  was  a  dream  comes  into  the  full  light  of  conscious- 
ness. With  this  realization  the  terrors  and  all  the  bodily 
disturbances  cease. 

I  have  pointed  out  that  one  theory  of  the  mechanism  by 
which  ideas  become  dissociated  is  that  of  voluntary  repression ; 
the  individual  pushes  out  of  his  consciousness  ideas  which  are 


The  Psychological  Principles  and  Field  of  Psychotherapy  43 

painful  and  unacceptable.  Consequently  it  is  held  by  those 
who  adopt  this  theory  that  those  dissociated  ideas  must  be 
resynthesized  with  the  personality,  i.e.,  brought  to  the  full 
light  of  awareness  —  to  effect  a  complete  and  permanent 
cure,  and  that  the  mere  act  of  making  the  patient  aware  of 
them  effects  the  cure.  To  accomplish  this  a  special  form  of 
psycho-analysis  (Freud's)  has  been  devised,  not  only  to 
discover  the  dissociated  ideas,  but  to  synthesize  them. 

That  this  method  is  often  useful  and  efficacious  will  be 
admitted,  but  its  mode  of  working,  as  I  interpret  it,  is  not 
that  which  those  who  employ  it  suppose.  Like  other 
methods  too,  it  is  not  always  successful  nor  is  it  the  only 
effective  one. 

Thus  it  is  often  not  difficult  by  suggestion,  with  or  with- 
out hypnosis,  along  the  lines  I  have  described,  to  effect  a  cure 
although  the  patient  never  becomes  aware  of  the  troubling 
ideas.  More  than  this,  it  is  worth  while  insisting  that  if 
psycho-analysis  merely  synthesizes  the  repressed  ideas 
theoretically  it  is  not  the  logical  method  to  be  employed. 
The  assumed  mechanism  would  require  something  more. 
The  repressed  ideas  are  pushed  into  the  subconscious 
because  they  are  in  conflict  with  other  wishes  and  feelings 
of  the  individual;  the  latter  rebels  against  and  will  not  toler- 
ate them.  Now  if  nothing  more  were  done  than  to  bring  them 
back  into  the  consciousness  of  the  individual  he  still  would 
not  tolerate  them  and  would  push  them  out  again.  Theo- 
retically, therefore,  the  method  would  be  useless.  But  in 
fact  the  patient  does,  we  will  say,  tolerate  the  ideas  that 
before  were  unbearable;  the  conflict  ceases.  Empirically 
the  method  works.  Why?  The  reason  is  simple:  the  com- 
plex of  ideas  has  been  changed  by  the  technique  of  psycho- 
analysis and  by  the  very  act  of  bringing  to  the  light  of  con- 
sciousness the  repressed  ideas — an  elaborate  process.  We  do 
more  than  this:  we  give  the  patient  an  insight  into  the  mean- 
ing of  his  trouble;  we  let  him  see^new  points  of  view;  we 


44  Psychotherapeutics 

introduce  new  ideas  and  feelings  into  his  complexes;  in 
short,  re-educate  him.  It  is  impossible  to  practice  psycho- 
analysis without  doing  this;  hence,  it  is  nothing  more  than 
a  special  form  of  the  educational  treatment  and  has  the  same 
therapeutic  value. 

When  the  hysterical  manifestations  are  due  to  the 
functioning  of  dissociated  subconscious  ideas  it  is  not  always 
necessary,  as  some  writers  insist,  to  recall  those  ideas  to  the 
personal  waking  consciousness.  It  is  enough  to  break  up 
the  subconscious  complex  or  to  suggest  antagonistic  ideas,  or 
to  resynthesize  the  ideas,  in  the  manner  already  described, 
into  a  healthy  complex  which  gives  a  true  appreciation  of 
the  facts  which  they  represent.  This  can  be  done  in  hyp- 
nosis. After  waking,  though  amnesia  for  the  previous 
subconscious  ideas  may  persist,  the  symptoms  disappear, 
for  those  harmful  subconscious  ideas  which  caused  the 
trouble  have  ceased  to  exist. 

Some  hysterical  attacks  are  what  have  been  aptly 
called  by  Boris  Sidis  recurrent  mental  and  psychomotor 
states;  that  is,  dissociations  of  the  personality  and  the  repro- 
duction of  systems  of  ideas  which  originally  were  an  emo- 
tional mental  accident  that  the  patient  once  upon  a  time 
experienced.  These  experiences  have  been  conserved  as 
brain  residua  and  come  to  life  again  from  time  to  time  as 
attacks.  If  a  rearrangement  of  these  conserved  experiences, 
by  education  along  the  lines  already  laid  down,  can  be 
brought  about,  a  disappearance  of  the  attacks  may  be  ex- 
pected. 

Hysterical  attacks  that  are  due  to  auto-suggestion  can 
be  removed,  as  a  rule,  by  simple  suggestion.  Automatisms, 
like  contractures,  tics,  spasms,  convulsions  and  crises,  tend 
to  cease  with  the  restoration  of  the  fully  synthesized  per- 
sonality if  the  dissociating  apprehensions  and  emotions  have 
been  removed  and  healthy  complexes  have  been  substituted 
therefor. 


The  Psychological  Principles  and  Field  of  Psychotherapy  45 

Whatever  technical  methods  are  employed,  it  will  be 
found  that  they  are  all  based  on  the  psychological  principles 
which  have  been  above  discussed. 

It  is  needless  to  insist  that  a  preliminary  psycho-analysis 
is,  as  always  in  psychotherapy,  a  prerequisite  procedure. 


46  Psychotherapeutics 

PSYCHASTHENIA  AND  OBSESSIONS 

In  so-called  psychasthenia  we  are  dealing  with  a  some- 
what different  pathological  condition  from  hysteria.  Here 
we  have  recurrent  mental  states  in  the  form  of  obsessions, 
represented  by  doubts,  scruples,  anxieties,  phobias,  impul- 
sions, etc.  The  obsessional  ideas  are  preserved  as  brain 
residua.  When  stimulated,  instead  of  becoming  subcon- 
scious, they  enter  the  consciousness  of  the  principal  person- 
ality. The  obsessional  ideas  occur  in  the  form  of  attacks 
of  which  psycho-analysis  will  not  only  show  the  origin  and 
meaning  but  that  the  attack  in  each  instance  is  excited  by 
association  with  some  related  thought  which  has  flashed 
into  the  mind  or  other  stimulus  from  the  environment.  Ap- 
prehension and  expectation,  acting  as  auto-suggestion,  play 
in  my  experience  a  predisposing  part  in  the  mechanism. 
The  pathology  is  too  complex  to  go  into  here,  but  the  same 
psychological  principles  underlie  the  psychotherapy,  viz., 
psycho-analysis  and  education,  the  latter  having  for  an  end 
the  substitution  of  healthy  complexes  for  those  organized 
systems  of  associated  ideas  which  have  become  conserved 
as  residua  in  the  unconscious  and  which  reproduce  them- 
selves as  automatisms  over  and  over  again. 


THE  THERAPEUTIC  VALUE  OF  HYPNOTIC 
SUGGESTION 

BY   FREDERIC    HENRY   GERRISH,   M.D.,    LL.D. 

Professor  of  Surgery,  Bowdoin  College 


THE  THERAPEUTIC  VALUE  OF  HYPNOTIC 
SUGGESTION 

IT  is  important  that  hypnotic  suggestion  should  not  be 
confounded    with    other    psychotherapeutic    methods 
—  it  is  only  one  of  various  psychic  means  by  which 
curative  results  can  be  attained;  and  in  my  advocacy 
of  it  as  a  valuable  remedy  there  is  no  intention  to  disparage 
or  belittle  any  of  the  other  psychotherapeutic  methods,  or 
even  to  institute  a  comparison   between  it  and  them.     We 
ought  to  have  a  scientific  acquaintance  with  all  of  them,  so 
that  we  can  select  whatever  method  is  best  adapted  to  any 
case  in  which  some  psychic  remedy  is  needed.     It  is  perti- 
nent to  remark  at  this  point  that,  as  hypnotic  suggestion  is 
treated  in  this  essay,  it  will  not  be  included  in  the  topics 
of  the  symposium  on  psychotherapy. 

Although  the  history  of  hypnotism  is  intensely  interest- 
ing, nothing  of  it  will  be  given  here,  as  our  time  is  quite 
sufficiently  occupied  with  more  important  matters.  For 
the  same  reason  the  various  theories  which  have  been 
advanced  to  account  for  its  phenomena  will  not  be  rehearsed. 
Even  that  evolved  by  modern  psychology  will  not  be  given, 
as  Dr.  Prince,  who  will  open  the  symposium,  is  to  discourse 
upon  the  principles  involved  in  the  different  phases  of  the 
broad  subject,  and  may  be  relied  on  to  do  the  work  in  a 
masterly  way.  My  humbler  task  will  be  to  set  forth  the 
practical  usefulness  of  hypnotism  in  the  daily  routine  of 
medical  work,  and  to  clear  away  many  misconceptions 
which  have  prevented  the  general  employment  of  this  agency. 
We  are  all  amenable  to  suggestion  in  greater  or  smaller 
degree.  The  training  of  the  infant  is  almost  wholly  by 
suggestion.  To  a  less  but  yet  to  a  very  important  extent 
the  same  method  is  operative  on  the  older  child  —  the 
example  of  his  associates  in  the  family  or  out  of  it  is  more 
potent  in  the  formation  of  his  character  and  habits  than  are 

49 


50  Psychotherapeutlcs 

all  the  precepts  that  are  dinned  into  him.  As  one's  years 
increase  the  susceptibility  to  suggestion  gradually  diminishes, 
apparently  just  in  proportion  to  the  loss  of  naturalness  and 
the  cultivation  of  the  artificial  restraints  which  convention 
imposes.  Suggestibility  is  generally  commensurate  with 
simplicity  of  nature.  In  full  maturity  we  have  become  so 
cautious  that  we  involuntarily  distrust  the  suggestions  that 
come  to  us  —  an  incredulous,  perhaps  even  a  cynical,  element 
has  crept  into  our  natures,  which  prompts  resistance  and 
demands  that  reason  shall  be  convinced.  And  yet  some 
suggestibility  remains  —  the  hardest  headed  of  us  can  be 
reached  by  a  sufficiently  frequent  and  skilful  repetition  of  a 
suggestion.  This  suggestibility  is  the  basis  of  the  benefit 
that  undoubtedly  comes  to  the  patient  from  the  cheerfulness 
of  the  physician,  from  his  heartening  words,  from  his  con- 
fident assurance  that  recovery  is  ahead,  from  his  strong 
personality  and  appearance  of  wellbeing  —  for  health  is, 
in  a  measure,  catching,  as  well  as  disease  —  from  his  irradia- 
tion of  strength,  of  comfort,  and  of  courage.  Now,  in  the 
condition  which  is  known  as  hypnosis,  suggestibility  is  mar- 
velously  increased.  Suggestions  which  in  the  ordinary  con- 
dition of  the  personality  are  unheeded,  in  the  hypnotic  state 
are  accepted  with  avidity.  So  large  is  this  hospitality  that 
almost  any  suggestion  will  be  welcomed  that  is  not  repug- 
nant to  the  moral  sense  of  the  hypnotized  person.  This 
eagerness  for  suggestion  may  be  taken  advantage  of  in  thera- 
peutics. If  the  patient  is  the  victim  of  a  disease  to  which 
the  name  "  functional  "  is  usually  applied,  and  can  be  hyp- 
notized, he  has  a  good  chance  of  getting  relief  through  the 
agency  of  suggestion ;  if  his  malady  is  organic,  a  cure  is  not 
to  be  expected.  (The  words  "  functional  "  and  "organic  " 
are  here  used  in  their  ordinary  sense,  as  a  matter  of  con- 
venience.) *For  example,  the  patient  has  insomnia,  not  due 
to  any  appreciable^structural  change.  He  is  hypnotized, 
and  the  suggestion  is  made  that  he  will  go  to  sleep  as  soon  as 


The  Therapeutic  Value  of  Hypnotic  Suggestion       51 

he  goes  to  bed,  and  remain  in  slumber  a  given  number  of 
hours,  'i;  He  is  then  brought  out  of  the  hypnotic  state,  and 
experiences  no  immediate  effect  of  the  treatment.  Perhaps 
he  is  utterly  incredulous,  and  derides  the  idea  that  a  notice- 
able impression  will  follow  the  process.  But,  if  he  is  as  sug- 
gestible as  the  average,  when  he  goes  to  bed,  he  tumbles  into 
sleep,  and  continues  in  sleep  subtantially  as  predicted;  or, 
if  sleep  has  been  suggested  for  a  particular  hour,  he  goes  to 
sleep  when  the  time  comes,  unless  he  makes  the  most  strenu- 
ous efforts  to  keep  awake  and  beat  off  his  drowsiness. 

The  hypnotic  state  is  induced  not  because  it  is  in  itself 
curative,  but  because  that  condition  is  peculiarly  favorable 
to  the  reception  and  retention  of  suggestions.  It  is  a  question 
of  the  relation  of  soil  and  seed.  In  the  ordinary  waking  state 
the  seed  of  suggestion  falls  on  the  stony  ground  of  indiffer- 
ence, which  is  hostile  to  its  development,  or  on  ground  where 
the  rank  weeds  of  conventional  usage  spring  up  and  choke 
it;  but  the  hypnotic  condition  furnishes  the  richest  kind  of 
loam  for  suggestions,  and  in  it  they  take  root  and  rapidly 
grow  up  and  bear  fruit  abundantly. 

Hypnosis  should  not  be  regarded  as  an  abnormal,  a 
pathologic  condition  —  it  is  simply  unusual.  Individuals 
differ  widely  in  their  capacity  for  hypnotization,  for  at  one 
extreme  are  some  who  cannot  be  put  into  that  state,  and 
at  the  other  end  of  the  scale  are  some  who  seem  to  be 
almost  hypnotized  all  of  the  time. 


52  Psychotherapeutics 

METHODS    OF    INDUCING    HYPNOSIS 

Hypnosis  may  be  induced  in  various  ways.  That  which 
will  be  described  has  proved  serviceable.  (It  is  assumed 
that  the  patient  consents  to  be  hypnotized,  and,  more  than 
that,  is  willing  to  co-operate  with  the  physician.)  First, 
the  process  is  explained  to  the  patient,  who  probably  has 
hardly  a  single  correct  idea  on  the  subject,  and  needs  to  have 
his  misconceptions  removed.  He  is  told  a  number  of  things, 
such  as  follow: 

1.  That  all  persons  are  more  or  less  amenable  to  sug- 
gestion in  the  ordinary  waking  condition,  as  is  illustrated 
in  many  familiar  ways,  such  as  gaping  involuntarily,  even 
against  one's  strenuous  attempts  to  avoid  it,  on  seeing  another 
yawn;    beating  time  unconsciously  on  hearing  the  measured 
throb  of  martial  music;  becoming  wildly  excited  for  no  other 
reason  than  that  one's  companions  are  panic-stricken;    and, 
contrariwise,   having  one's   fears   allayed   by  the   tranquil 
appearance  of  his  associates  in  a  terrible  emergency. 

2.  That,  in  some  way,  the  mental  mechanism  of  which 
is  not  thoroughly  understood,  when  a  person  is  hypnotized, 
he  accepts  suggestions  more  readily  than  when  he  is  in  his 
usual  condition;    and  that  hypnosis  is  induced  only  for  the 
purpose  of  taking  advantage  of  this  fact,  and  thus  enabling 
the  patient  to  receive  the  benefit  of  suggestions,  to  which,  in 
his  ordinary  mental  state,  he  is  practically  impervious. 

3.  That  no  harm  to  the  patient  in  any  direction  will 
result  from  the  hypnotizing,  either  immediately  or  at  any 
future  time. 

4.  That  the  patient  is  not  desired  to  surrender  his  will, 
but,  on  the  contrary,  is  asked  to  exercise  it  in  co-operation 
with  the  physician. 

5.  That  he  is  not  to  expect  to  lose  consciousness,  for 
the  lighter  degrees  of  hypnosis  are  sufficient  for  the  accom- 
plishment of  remedial  results  in  all  but  a  minority  of  cases. 


The  Therapeutic  Value  of  Hypnotic  Suggestion        53 

6.  That  the  word  "  sleep  "  in  this  connection  is  a  term 
of  convenience,  and  means  only  that    early  stage  of  sleep 
that  is  consistent  with  consciousness:    a  transitional    stage 
which  any  one  who   has   analyzed  his  sensations  has  recog- 
nized as  a  brief  period  immediately  preceding  the  uncon- 
sciousness of  slumber,  when  by  an  effort  he  can  become  wide- 
awake, or  by  lying  still  and  guarding  his  mind  against  ex- 
citing thoughts  can  insure  speedy  and  perfect  sleep. 

7.  That  there  will  be  nothing  unpleasant  in  the  process 
—  no  shock,  no  electric-like  thrill,  no    startling  sensation; 

but  that,  if  the  attempt  is  successful,  he  will  experience  a 
feeling  as  if  tension  was  relaxed,  a  mental  and  physical  calm, 
a  soothing  drowsiness. 

8.  That   he   must   not   be   discouraged   by   complete 
failure  at  the  first  attempt,  as  it  often  happens  that  the  excite- 
ment, incident  to  the  novelty  of  the  situation,  defeats  the 
efforts  of  both  parties;    and  that,  when  he  perceives,  as  he 
will  from  observing  the  process  pursued,  that  there  is  nothing 
ungentle  or  in  any  way  objectionable  about  it,  there  will 
probably  be  no  difficulty  in  achieving  success. 

9.  That  the  suggestions  will  be  made  more  emphati- 
cally than  will  seem  to  him  necessary;     for  example,  if  a 
night's  sleep  is  desired,  it  will  be  suggested  that  he  will  get 
twelve  hours,  this  being  on  the  principle  followed  by  a  marks- 
man in  putting  up  his  sight  for  a  long  shot.     If  the  barrel  of 
the  weapon  is  directed  exactly  at  the  bull's-eye,  the  force  of 
gravity  will  draw  the  projectile  downward,  and  the  mark  will 
be  hit  below  the  center,  if  at  all.    So,  too,  allowance  must  be 
made  for  the  downward  deflection  of  a  suggestion  in  an  in- 
veterate or  otherwise  difficult  case.     As  the  sight  of  the  rifle 
must  be  raised  so  that  the  barrel  is  aimed  above  the  mark, 
so   the    suggestion    must  be  exaggerated,  must    be    aimed 
high,  in  order  to  reach  the  desired  point. 

10.  That  the  patient  must  not  contradict  or  resist,  and 
must  not  try  to  open  his  eyes  until  permission  is  given  him. 


54  Psychotherapeutics 

The  patient,  thus  instructed,  then  lies  down  on  a  couch, 
or  seats  himself  in  a  lounging  chair,  in  which  he  has  a  com- 
fortable rest  for  his  head.  He  is  told  to  concentrate  his 
attention  upon  sleep,  to  try  to  go  to  sleep;  and,  to  assist  him 
in  this  effort  by  preventing  his  taking  in  distracting  ideas 
through  his  eyes,  as  they  wander  around  the  room  and  see 
the  pictures,  books,  and  furniture,  he  is  asked  to  fix  his 
gaze  upon  some  indifferent  object,  as,  for  example,  the 
finger  of  the  physician,  which  is  held  a  foot  or  so  from  the 
face  of  the  patient.  He  is  instructed  not  to  try  to  keep  his 
eyes  open,  and  not  to  close  them  voluntarily,  but  merely  to 
let  the  lids  go  as  they  will.  The  physician  places  his  free 
hand  upon  the  forehead  of  the  patient,  and,  by  a  continuous 
stream  of  quiet,  monotonous  talk,  encourages  the  patient 
in  his  effort  to  go  to  sleep.  For  example,  he  says,  "  Try  to 
sleep,  think  of  nothing  but  sleep,  keep  your  thoughts  fixed 
upon  going  to  sleep.  Your  lids  are  heavy,  they  are  drooping, 
you  are  going  to  sleep.  Every  moment  you  are  getting  more 
drowsy;  you  feel  the  sleep  stealing  over  you.  The  lids  are 
closing;  you  are  almost  asleep.  Now  the  eyes  have  closed; 
you  have  gone  to  sleep."  Meantime  a  little  pressure  has  been 
made  upon  the  brows;  and,  when  the  lids  slip  down  and 
cover  the  eyes,  they  are  gently  stroked.  The  hand  is  kept 
upon  the  forehead,  and  the  physician  enforces  his  assur- 
ances by  some  such  words  as  these:  '  You  are  asleep, 
though  you  have  not  lost  consciousness.  You  hear  my 
voice,  the  sounds  in  the  house,  the  noises  in  the  street  —  and 
yet  you  are  asleep.  You  feel  the  sleep  all  through  you  — 
head,  trunk,  and  limbs  are  all  heavy  with  sleep.  Your 
nerves  are  all  relaxed,  there  is  no  tension  anywhere,  you  are 
perfectly  tranquilized.  You  will  not  move  a  muscle,  except 
to  breathe,  until  I  bid  you  wake." 

This  process  may  take  a  minute,  or  it  may  occupy  a 
quarter  hour;  but  when  it  is  completed  the  patient  is  ready 
for  the  remedial  suggestions  —  the  soil  is  prepared  for  the 


The  Therapeutic  Value  of  Hypnotic  Suggestion        55 

seed.  Then  the  physician  makes  the  necessary  suggestions, 
speaking  them  plainly,  putting  them  strongly,  repeating  them, 
emphasizing  them  in  the  most  positive  and  insistent  way. 
Generally  he  cannot  tell  how  much  effect  has  been  produced; 
but  something  can  be  judged  by  the  degree  of  quietude  of  the 
patient.  If  he  is  perfectly  still,  the  probability  is  that  all  is 
working  well;  but  certain  limited  movements  are  not  incon- 
sistent with  fine  success.  A  constant  quivering  of  the  lids 
is  sometimes  observed  in  the  profoundest  stage  of  hypnosis; 
but  swallowing  commonly  indicates  that  only  a  slight  degree 
has  been  reached. 

Having  finished  the  remedial  suggestions,  others  are 
made  to  the  effect  that  the  hypnotic  state  can  be  induced 
more  readily  at  each  subsequent  session,  that  the  patient  can 
be  hypnotized  whenever  he  wishes  it,  and  particularly,  that 
he  can  never  be  hypnotized  by  anybody  without  giving  his 
entire  consent.  In  this  way  the  patient  is  locked  against 
the  attempts  of  designing  hypnotizers,  and  may  successfully 
defy  any  efforts  to  control  him  in  this  manner. 

All  of  the  suggestions  appropriate  to  the  case  having  been 
made,  the  patient  is  allowed  to  remain  quiet  for  a  longer  or 
shorter  time,  according  to  the  seriousness  of  the  condition  — 
a  few  minutes  or  more  than  half  an  hour;  and  the  effect  is 
deepened  by  a  gentle  though  emphatic  repetition  of  the 
suggestions.  When  the  time  for  rousing  the  patient  comes 
the  physician  says,  "  You  may  wake  now."  Sometimes 
the  awakening  will  be  prompt,  sometimes  slow  and  reluctant, 
the  latter  being  more  likely  when  the  hypnosis  has  been 
profound.  If  no  permission  to  wake  were  given,  the  hypnotic 
condition  would  gradually  disappear,  and  the  patient  would 
rouse  himself  as  from  ordinary  sleep. 

This  method  need  not  be  followed  in  detail;  indeed, 
every  hypnotizer  develops  his  individual  procedure,  and  finds 
his  own  the  best  for  his  purposes.  But  there  are  common 
features  in  all  of  them,  the  essentials  —  quietude,  confidence, 


56  Psychotherapeutics 

gentleness,  discreet  sympathy,  intelligent  appreciation  —  are 
practiced  in  various  ways. 

After  a  very  few  successful  sessions  it  becomes  unneces- 
sary for  the  patient  to  begin  the  process  with  open  eyes;  he  is 
instructed  to  close  them  at  the  first,  and  the  physician  gently 
strokes  the  forehead  and  then  the  eyelids,  speaking  words 
which  encourage  the  patient  to  sleep,  and  in  a  few  moments 
hypnosis  is  effected.  More  than  this,  even,  in  the  case  of 
some  peculiarly  susceptible  persons,  the  spoken  command 
is  sufficient  for  the  induction  of  the  desired  condition. 

In  chronic  cases  it  is  generally  necessary  to  have  many 
sessions  with  the  patient,  and  speedier  results  are  attained, 
if  the  intervals  are  short.  This  method  of  treatment  is  com- 
parable with  that  by  medicines  —  the  doses  must  be  given 
frequently  in  order  to  keep  the  system  impressed,  as  other- 
wise the  effect  of  one  wears  off  before  another  is  administered. 

Much  time,  great  persistency,  vast  patience,  abundant 
good  nature  and  tact  are  needed  in  the  inveterate  cases. 
Perseverance  in  attempts  to  hypnotize  will  sometimes  be 
rewarded  with  brilliant  results,  even  though  many  early 
trials  have  utterly  failed. 

Having  discussed  the  nature  of  hypnotism,  and  described 
the  methods  of  its  induction,  we  now  come  to  the  considera- 
tion of  the  conditions  in  which  it  can  be  advantageously 
employed. 


The  Therapeutic  Value  of  Hypnotic  Suggestion        57 
CONDITIONS  IN  WHICH  HYPNOTIC    SUGGESTION    IS    VALUABLE 

Some  authorities  think  that  it  is  unscientific  to  separate 
functional  and  organic  diseases,  that  there  is  no  per- 
version of  action  independent  of  an  alteration  in  structure. 
And  yet,  a  practical  discrimination  may  properly  be  made 
without  offending  pathologic  proprieties;  and  I  trust  that, 
for  convenience,  it  is  permissible  for  me  to  employ  the  terms 
in  their  ordinary  signification.  Assuming,  then,  your  in- 
dulgent forbearance,  it  may  be  said  that,  in  a  general  way, 
hypnotic  suggestion  finds  its  field  in  the  domain  of  functional 
diseases  of  the  nervous  system.  It  may  be  used  advantage- 
ously in  relieving  some  of  the  sufferings  incident  to  organic 
diseases;  but  in  these  cases  it  is  only  palliative  and  not 
curative.  It  is  not  claimed  that  all  patients  afflicted  with 
scuh  disorders  as  usually  yield  to  suggestion  will  be  helped 
by  this  treatment;  but  in  this  respect,  as  in  others,  the  remedy 
resembles  therapeutic  agencies  of  physical  character.  It  is 
not  reasonable  to  look  for  universal  success  with  any  agent, 
or  to  expect  that  every  patient  will  respond  to  any  treatment 
as  does  the  average  one.  The  ailments  in  which  hypnosis 
is  of  the  most  conspicuous  value  are  those  characterized  by 
pain,  insomnia,  abnormal  nervous  irritability,  depression  of 
spirits,  phobias,  obsessions,  neurasthenia,  moral  obliquity, 
spasm,  nausea,  sexual  perversions,  and  drug  habits.  The 
cases  which  will  be  cited  in  illustration  occurred  in  my  own 
practice,  and  are  selected  almost  at  random  from  a  vast 
number.  The  reports  are  necessarily  limited  to  the  essen- 
tial features  in  order  to  keep  this  paper  within  reasonable 
bounds. 

Pain.  A  man  of  45  years  of  age  had  been  operated 
on  twice  for  trifacial  neuralgia.  After  each  operation  he 
had  experienced  a  year  of  comfort,  and  then  the  trouble 
returned  violently.  The  removal  of  the  ganglion  was  all 
that  surgery  offered  at  that  time,  and  from  this  he  shrank 


58  Psychotherapeutlcs 

on  account  of  the  danger  to  life;  but  he  was  willing  to  try 
hypnotism.  When  he  presented  himself  in  my  office,  and 
tried  to  answer  a  question,  the  effort  threw  the  muscles  of 
one  side  of  his  face  into  such  a  spasm,  attended  evidently 
with  extreme  pain,  that  he  motioned  to  his  wife  to  speak 
for  him.  His  diet  was  restricted  to  liquids,  because  chewing 
meant  agony;  and  he  was  compelled  to  almost  complete 
silence,  because  of  the  direful  penalty  of  speech.  He  had  a 
treatment  twice  daily  for  ten  days.  From  the  first  day  he 
was  measurably  relieved,  and  he  had  no  pain  after  the  fourth 
day.  His  wife  went  home  at  the  end  of  a  week,  as  she  was 
no  longer  needed  as  nurse  and  interpreter;  and  he  followed 
on  the  tenth  day,  declaring  that  there  was  no  need  of  remain- 
ing, as  he  was  perfectly  well,  and  he  could  return  at  any 
time  if  his  trouble  came  back.  His  abandonment  of  treat- 
ment was  against  my  judgment  and  advice,  for  the  case  was 
too  chronic  and  severe  to  justify  the  expectation  that  it  could 
be  permanently  relieved  in  so  brief  a  time;  but  he  never 
returned,  or  reported  in  any  way.  But  even  supposing  that 
there  was  not  a  cure,  the  effect  of  the  treatment  illustrates 
the  availability  of  the  remedy  and  its  advantages  over 
physical  anodynes,  which,  in  producing  an  equal  effect, 
would  almost  certainly  establish  a  drug  habit. 

Insomnia.  A  great  affliction,  prolonged  overwork,  and 
anxiety  had  so  affected  a  man  of  35  years,  that  his  capacity 
for  sleep  was  seriously  reduced.  For  three  months  he  had 
slept  only  two  or  three  hours  in  the  twenty-four,  and  not 
only  felt  ill,  but  looked  haggard  and  worn.  A  single  hyp- 
notic treatment  refreshed  him  greatly.  He  was  instructed 
to  come  daily  for  a  while,  as  the  case  was  chronic  and  severe; 
but  a  month  went  by  without  my  seeing  him.  Then  at  a 
chance  meeting  he  was  asked  to  give  an  account  of  himself - 
why  he  had  not  come  often,  as  he  had  promised.  He  joy- 
ously replied,  "  What's  the  good  of  going  to  a  doctor  when 
one  is  perfectly  well  ?  I  slept  like  a  log  all  that  night,  and 


The  Therapeutic  Value  of  Hypnotic  Suggestion        59 

I've  slept  like  a  log  every  night  since."  Many  years  have 
passed,  and  he  has  had  no  recurrence  of  insomnia. 

Nervous  Irritability.  A  young  matron  applied  for 
relief  of  pronounced  hyperesthesia.  Her  sensibilities  were 
constantly  on  edge.  The  slightest  sound,  like  that  attending 
the  lighting  of  a  gas  jet,  if  it  came  as  a  surprise,  would  set 
her  nerves  aquiver  for  an  hour.  In  railway  travel  she  always 
felt  obliged  to  take  the  most  remote  available  seat  in  the  last 
car  of  the  train  in  order  to  be  as  far  away  as  possible  from  the 
noise  of  the  bell  and  the  whistle  of  the  locomotive.  Life  was 
a  series  of  alarms  and  distresses.  The  first  attempt  at  hyp- 
nosis was  an  utter  failure  —  the  patient  was  wrought  up  to 
the  highest  pitch  of  excitement,  and  therefore  could  not 
concentrate  her  attention  in  the  needed  direction.  She  was 
in  despair,  feeling  certain  that  her  last  hope  of  relief  had 
vanished,  and  no  encouraging  assurances  had  any  effect. 
Two  days  afterward  a  second  visit  was  made.  The  patient 
was  in  tears,  mourning  over  the  assumed  impossibility  of 
being  hypnotized.  While  she  was  in  that  state  of  mind  it 
was  plainly  useless  to  attempt  hypnosis,  so  the  effort  was 
made  to  distract  her  attention  from  herself.  For  an  hour 
nothing  was  said  about  patient  or  sickness  or  anything 
depressing,  and  the  time  was  spent  in  the  recital  of  droll 
stories  and  in  whatever  else  might  help  to  divert  the  self- 
centered  and  morbid  current  of  her  thought.  At  what 
seemed  a  favorable  moment  she  was  told  to  close  her  eyes, 
and  she  obeyed  instantly.  The  lids  were  gently  stroked, 
and  hypnotization  was  accomplished  in  that  moment. 
Suitable  suggestions  were  made,  and  the  cure  promptly 
began,  and  was  finished  in  a  few  weeks.  Tranquility  suc- 
ceeded excitement,  and  life  took  on  a  very  different  aspect. 

This  case  shows  that  primary  failure  is  no  indication  of 
ultimate  results.  Excitement  is  inimical  to  hypnosis,  as  it 
is  to  true  sleep;  and  the  patient  should  not  only  be  willing, 
but  calm  enough  to  be  able  to  concentrate  his  attention. 


60  Psychotherapeutics 

Depression  of  Spirits.  A  man  of  30  years,  gifted,  well 
educated,  and  of  fine  character  but  moody  disposition,  had 
been  afflicted  for  many  months  with  extreme  depression, 
which  he  was  utterly  unable  to  throw  off.  He  was  not  a 
good  hypnotic  subject;  but  he  was  practically  restored  in 
a  fortnight  of  daily  sessions.  He  became  cheerful,  regained 
interest  in  his  work,  liked  to  mingle  with  his  friends,  and  now, 
after  many  years,  is  in  full  enjoyment  of  life. 

Fear  of  Travel  on  the  Water.  A  gentleman  whose 
occupation  occasionally  required  him  to  make  little  journeys 
to  the  islands  in  the  harbor  had  constitutionally  so  great 
a  dread  of  water-travel  that  sometimes  he  would  leave  the 
steamboat  just  as  it  was  about  to  start,  abandoning  the  pro- 
jected trip,  even  though  he  appreciated  the  urgency  of  his 
business,  which  always  involved  the  interests  of  others  as 
well  as  his  own.  After  a  few  hypnotic  sessions  he  was  able 
to  make  excursions  on  the  boats,  not  only  without  mental 
disturbance,  but  even  with  some  enjoyment. 

Extreme  Timidity.  A  lady  in  early  middle  life  gave  this 
account  of  her  case:  "  Before  my  marriage  I  was  a  teacher, 
and  experienced  no  trouble  in  addressing  a  roomful  of  people 
whenever  my  work  required  it.  But  for  seventeen  years  I 
have  never  appeared  before  an  audience.  To-morrow  after- 
noon I  am  announced  to  read  a  paper  before  one  of  the  large 
clubs  of  women,  and  I  am  frightened  almost  to  death  at  the 
thought.  My  paper  is  a  good  one,  and  I  am  not  at  all  afraid 
that  it  will  not  be  satisfactory;  but  when  I  try  to  read  it 
aloud  at  home  and  entirely  alone,  I  break  down;  I  cannot 
help  seeing  that  critical  audience,  and  the  thought  of  it  scares 
me  so  that  I  have  to  stop.  Can  you  not  hypnotize  my  terror 
out  of  me,  and  put  courage  in  its  place  ?  "  She  was  an  entire 
stranger  to  me,  and  the  prospect  for  success  was  not  flattering. 
Besides,  my  time  was  so  engaged  that  it  was  impracticable 
to  make  an  appointment  before  the  next  noon.  Then,  only 
two  hours  before  the  meeting  at  which  she  was  to  perform, 


The  Therapeutic  Value  of  Hypnotic  Suggestion        6l 

she  received  the  hypnotic  suggestion  which  she  desired. 
The  next  day  she  called  to  report.  Her  face  was  radiant, 
and  she  gave  an  enthusiastic  account  of  herself,  saying,  "  I 
had  no  fear,  no  difficulty  whatever  in  reading.  A  lot  of  the 
women  were  moved  to  tears,  and  when  I  was  through  my 
friends  thronged  around  me  with  their  congratulations  and 
praised  not  only  my  essay  but  the  way  in  which  I  read  it. 
But  I  told  them  that  all  the  credit  for  that  should  be  given 
to  hypnotism."  As  her  name  has  often  appeared  in  connec- 
tion with  public  performances  since  then,  it  is  fair  to  suppose 
that  she  has  had  no  further  difficulty. 

This  case  may  strike  some  as  trivial,  and  so  it  is  as  com- 
pared with  many  or  most  of  those  with  which  we  have  to 
deal.  But  it  does  not  seem  to  me  unworthy  of  the  efforts 
of  a  physician.  The  slight  ailments  need  wise  treatment, 
and  their  correction  may  prevent  serious  illness,  may  even 
save  life.  A  disturbance  such  as  this  woman  had  may  easily 
enough  be  the  initial  step  in  a  series  that  leads  to  an 
asylum;  but  being  corrected,  obstacles  are  removed  from 
the  path  to  happy  and  successful  endeavor. 

Obsession.  A  young  matron  from  her  earliest  recollec- 
tion had  been  in  constant  dread  of  assassination,  but  had 
never  mentioned  the  horror  until  she  revealed  it  to  me. 
Even  then  she  would  not  have  spoken  of  it  but  that  she 
had  been  relieved  of  neuralgia  by  hypnotic  suggestion,  and 
hoped  that  her  greater  trouble  could  be  dissipated  by  the 
same  means.  She  was  afraid  of  the  dark,  even  when  she 
had  a  companion,  and  she  never  allowed  herself  to  be 
left  in  the  house  alone.  Half  a  dozen  treatments  cured  her 
completely. 

Neurasthenia.  A  lady  of  43  years  for  a  whole  decade 
had  been  in  a  condition  of  nervous  prostration,  with  marked 
digestive  disturbances.  She  was  under  treatment  during 
the  whole  time,  but  had  received  no  benefit.  She  was  ad- 
vised to  try  the  effect  of  hypnotic  suggestion  by  a  physician 


62  Psychotherapeutlcs 

who  had  declared  to  me  with  great  positiveness  that  hyp- 
notism was  justifiable  only  in  absolutely  hopeless  cases,  in 
which  desperate  means  could  be  sanctioned.  After  a  pro- 
longed examination  the  conclusion  was  reached  that  no  organ 
was  appreciably  diseased.  She  was  given  treatment  every 
day  for  a  month,  but  long  before  that  time  had  elapsed  she 
was  practically  well.  Her  distresses  were  all  banished,  her 
feebleness  disappeared,  her  digestion  was  restored,  and  her 
spirits  became  buoyant. 

Moral  Obliquity.  A  lady  applied  in  deep  distress  of 
mind  concerning  her  ten-year-old  son,  a  strong,  healthy, 
genial,  little  fellow,  who  had  no  interest  in  his  school  duties, 
habitually  played  truant,  and  lied  in  the  most  abandoned 
manner.  His  nature  was  very  affectionate,  and  he  was  very 
fond  of  his  mother;  but  she  had  exhausted  her  means  of 
influencing  him  without  avail.  She  consented  to  have  hyp- 
notism tried  on  him.  In  three  weeks  his  parents  declared 
that  he  was  a  different  boy.  He  attended  school  regularly, 
took  good  rank  in  his  studies,  and  was  proud  of  it,  and  his 
word  could  be  relied  upon  implicitly. 

Asthma.  An  old  lady  who  had  suffered  from  asthma 
for  many  years  and  found  no  relief  beyond  slight  palliation, 
sent  for  me  when  she  was  having  a  severe  attack.  She  had 
never  been  hypnotized,  and  her  orthopnea  forbade  her  lying 
down  or  even  reclining,  but  she  could  endure  for  a  little 
while  a  slight  inclination  backward,  so  that  the  head  rested 
against  a  pillow.  In  this  position  she  was  quickly  hypno- 
tized, and  was  wholly  relieved  in  a  few  minutes. 

Seasickness.  A  young  lady  who  had  been  across  the 
Atlantic  several  times,  and  regularly  suffered  nausea  marina, 
appealed  to  me  for  prophylactic  treatment.  She  had  de- 
ferred the  matter  until  a  few  days  before  her  voyage,  and  the 
attention  which  it  was  possible  to  give  her  seemed  altogether 
inadequate,  but  the  event  was  happy.  She  was  not  at  all 
disturbed  during  the  journey,  and  took  her  meals  regularly 


The  Therapeutic  Value  of  Hypnotic  Suggestion        63 

with  enjoyment,  all  of  which  was  the  more  remarkable  as 
her  room-mate  was  violently  seasick  every  day  of  the  voyage, 
and  depended  upon  the  ministrations  of  my  patient  con- 
stantly. 

Sexual  Perversion.  Schrenck-Notzing  says  that  the 
grossest  sexual  aberrations,  even  when  they  are  deeply  rooted 
and  have  changed  the  entire  personality,  are  frequently  cured 
by  hypnotic  suggestion.  Krafft-Ebing,  in  his  Psychopathia 
Sexualis,  seems  to  depend  entirely  upon  this  remedy  in  the 
cases  of  which  he  speaks.  It  has  not  been  my  fortune  to 
have  as  a  patient  a  person  afflicted  with  any  of  these  maladies. 
But  a  case  was  sent  me  by  a  friend,  a  specialist  in  neurology, 
who  was  unable  to  help  the  patient,  and,  although  thinking 
lightly  of  hypnotism,  desired  me  to  try  it  in  this  case.  The 
patient  was  a  medical  student,  a  young  man  of  neurasthenic 
tendency,  who  was  hyperesthetic  sexually,  and  was  troubled 
especially  with  priapism.  He  was  hypnotized  several  times 
with  acknowledged  benefit,  but  ceased  his  visits  before  being 
discharged  as  cured.  One  day  my  neurologic  colleague 
called  on  me  and  reported  that  the  patient  was  apprehensive 
that  the  treatment  had  been  carried  too  far;  not  only  was  he 
relieved  of  his  priapism  and  other  evidences  of  his  sexual 
over-sensitiveness,  but  he  had  positive  sexual  apathy. 
Without  difficulty  the  normal  equilibrium  was  found  and 
established. 

Drug  Addictions.  An  apothecary,  about  30  years  of 
age,  had  the  alcohol  habit.  He  did  not  drink  intoxicants 
every  day,  but  once  in  a  few  weeks  he  drank  persistently 
until  his  stomach  revolted,  and  then  he  was  abstinent  until 
the  furore  for  alcohol  seized  him  again.  His  necessities 
prohibited  abandonment  of  his  work,  and  his  persistence  in 
it  kept  him  constantly  in  an  atmosphere  of  temptation.  No 
encouragement  to  expect  a  cure  under  these  circumstances 
was  given  him,  but  his  urgent  pleading  induced  me  to  try 


64  Psychotherapeutics 

the  effect  of  hypnotic  suggestion.  After  twenty  sessions  the 
treatment  was  given  up  on  account  of  my  absence  from  town 
for  nearly  two  months;  and  while  the  signs  were  hopeful,  it 
was  highly  improbable  that  he  would  not  relapse  into  his 
wretched  slavery.  But  he  did  not,  and  years  afterward  he 
remained  entirely  cured. 


The  Therapeutic  Value  of  Hypnotic  Suggestion         65 

CORRECTION     OF    MISCONCEPTIONS    CONCERNING    HYPNOTISM 

There  is  a  multitude  of  errors  concerning  hypnotism, 
which  are  almost  as  prevalent  among  physicians  as  in  the 
non-medical  population,  and  a  number  of  these  will  be  stated 
and  corrected. 

It  is  commonly  supposed  that  a  person  must  lose  con- 
sciousness in  the  process.  In  most  cases  the  patient  retains 
consciousness  perfectly.  For  the  production  of  some  results 
the  deepest  stage  of  the  hypnotic  condition  is  requisite;  but 
for  the  ordinary  therapeutic  effects  it  is  by  no  means  neces- 
sary. Brilliant  cures  are  sometimes  achieved  with  patients 
who  are  hardly  made  drowsy  by  being  hypnotized. 

It  is  a  prevalent  belief  that  only  the  weak-minded,  or, 
at  best,  the  hysteric,  are  amenable  to  hypnotic  suggestion. 
Nothing  could  be  farther  from  the  truth.  The  experienced 
hypnotizer  dislikes  to  deal  with  either  of  these  classes  of 
patients;  he  would  rather  for  every  reason  have  strong  men 
with  cultivated  minds  and  disciplined  wills.  The  physician 
who  uses  only  physical  therapeutic  means  prefers  the  well- 
balanced,  sensible,  intelligent  for  patients,  and  so  does  the 
one  who  employs  psychic  means,  and  for  the  same  reasons. 
The  hypnotizer  asks  his  patient  to  exert  his  will  in  a  specified 
direction;  he  wants  the  intelligent  co-operation  of  the  pa- 
tient, and  this  requirement  is  most  difficult  for  the  feeble- 
minded, the  untrained,  the  heedless  to  meet. 

Another  mistaken  notion  is  that  only  a  minority  of  per- 
sons can  be  hypnotized.  This  is  true  only  if  one  has  in  mind 
the  idea  that,  in  order  to  be  hypnotized,  one  must  lose  con- 
sciousness —  which  has  already  been  declared  to  be  an  error. 
The  great  majority  of  people  can  be  hypnotized  to  an  extent 
quite  sufficient  to  make  them  susceptible  to  remedial  sug- 
gestions. 

A  misconception  which  it  is  very  difficult  to  displace  as- 
cribes to  the  hypnotizer  a  peculiar  and  rare  natural  endow- 


66  Psychotherapeutics 

ment.  That  some  men  are  better  hypnotizers  than  others  is 
unquestionably  true,  just  as  some  men  are  more  capable  than 
others  in  any  line  of  activity.  He  who  has  a  strong  and  healthy 
physical  organism,  a  powerful  mind,  and,  perhaps  best  of  all, 
an  engaging  presence,  has  elements  that  make  for  success 
in  any  affairs  where  man  meets  man;  and,  of  course,  such  a 
one  gets  the  best  results  with  his  medicines,  with  his  surgical 
operations,  with  his  electrical  applications.  Why  should  he 
not  do  better  than  most  others  in  the  use  of  suggestion, 
hypnotic  or  non-hypnotic  ?  But  while  this  type  is  the 
highest,  there  are  others  who,  while  not  quite  or  nearly  as 
well  endowed,  are  yet  capable  of  excellent  work;  and  as 
they  will  pass  muster  in  the  other  styles  of  therapeusis,  so, 
too,  they  will  succeed  in  hypnosis.  Any  man  who  has  the 
attributes  which  every  medical  practitioner  should  possess 
can  practice  hypnotism.  But  he  must  believe  in  it,  and  he 
must  declare  his  belief  by  the  confidence  of  his  bearing. 
Self-distrust,  timidity,  uncertainty  in  the  physician  inevitably 
beget  reluctance,  fear,  and  antagonism  in  the  patient,  what- 
ever the  former  undertakes  to  do,  and  whatever  the  method 
by  which  he  essays  to  do  it. 

A  common  fallacy  ascribes  whatever  result  is  experi- 
enced to  a  mysterious,  subtile  emanation  from  the  physician 
which  enters  and  pervades  the  system  of  the  patient.  This 
error  is  partly  due  to  the  persistence  of  a  theory  which  was 
upset  long  ago;  and  partly,  doubtless,  to  the  likeness  which 
is  popularly  thought  to  obtain  between  hypnotism  and 
electricity.  The  real  explanation  is  suggestion,  pure  and 
simple. 

A  frequent  objection  is  that,  in  the  hands  of  an  un- 
scrupulous person,  great  wrong  may  be  perpetrated  by 
hypnosis,  and  therefore  it  should  not  be  used.  The  same 
line  of  argument  would  lead  us  to  abandon  treatment  by 
medicines,  because  it  must  be  admitted  that  patients  have 
been  killed  by  drugs  administered  by  physicians,  and  to 


The  Therapeutic  Value  of  Hypnotic  Suggestion         67 

give  up  cutting  operations  in  surgery,  because  many  persons 
have  died  on  account  of  these  procedures.  That  there  are 
scoundrels  and  incompetents  in  the  medical  profession,  as  in 
all  others,  is  a  lamentable  fact;  but  they  constitute  but  a 
small  minority,  and  the  danger  of  their  doing  harm,  mali- 
ciously or  innocently,  by  employing  hypnotism  is  exactly 
on  a  plane  with  the  peril  which  attends  their  practice  in  any 
other  line.  Every  real  authority  on  modern  hypnotism  says 
emphatically  that  a  suggestion  that  offends  the  moral  sense 
of  the  person  hypnotized  is  either  disregarded,  or  has  the 
effect  of  rousing  the  subject  immediately.  If  it  were  practi- 
cable to  incite  to  criminal  acts  through  the  agency  of  hypnotic 
suggestion,  there  would  be  no  lack  of  examples  of  this  fact; 
but  in  many  years  of  observation  not  an  authentic  case  of 
the  kind  has  come  to  my  knowledge.  The  possibilities  of 
such  a  method  in  the  hands  of  a  skillful  romancer  are  too 
obvious  to  escape  the  attention  of  novelists,  and  we  know 
that  thrilling  tales  of  absorbing  interest  have  been  pivoted 
on  this  supposition;  but  we  never  encounter  such  occurrences 
in  actual  life,  and  we  may  confidently  disabuse  our  minds 
of  this  groundless  apprehension. 

It  is  objected  that  hypnosis,  especially  if  often  repeated, 
weakens  the  will  of  the  patient  and  makes  him  dependent 
upon  the  mind  of  the  operator.  Such  a  result  is  imaginable, 
but  can  never  occur,  if  the  physician  is  as  careful  in  using  this 
agency  as  he  always  should  be  when  administering  drugs 
or  doing  surgery.  As  a  matter  of  fact  the  will  may  be 
strengthened  by  hypnotic  suggestion,  and  the  moral  vigor 
increased  in  every  respect.  All  of  the  cases  of  injury  from 
hypnosis  of  which  I  have  ever  heard  have  resulted  from  the 
reckless  employment  of  it  for  exhibition  purposes,  mostly 
by  irresponsible  mountebanks.  The  shows  conducted  by 
hypnotizers  for  the  amusement  of  popular  audiences  should 
be  sternly  repressed.  That  this  treatment  has  not  been  their 
fate  is,  in  my  opinion,  in  considerable  degree  to  be  ascribed 


68  Psychotherapeutics 

to  the  attitude  of  physicians.  Repeatedly  I  have  known 
doctors  to  accept  and  use  complimentary  tickets  to  these 
wretched  performances,  thus  tacitly  bestowing  their  pro- 
fessional sanction  on  indefensible  applications  of  hypnotism, 
while  at  the  same  time  they  display  a  strong  disposition  to 
outlaw  a  fellow  practitioner  who  brings  to  bear  upon  his 
patients  the  altogether  beneficent  uses  of  the  same  agency. 
If  used  discreetly,  hypnotism  does  not  induce  insanity,  does 
not  weaken  the  mind,  does  not  do  harm  in  any  direction. 

Hypnotism  should  be  used  only  by  educated  physicians, 
and  by  them  only  as  a  remedy  or  a  means  to  diagnosis. 
If  it  had  never  been  employed  outside  of  its  legitimate 
domain  there  would  be  little  or  nothing  of  the  prejudice 
against  it  which  is  constantly  encountered  in  the  community; 
and  the  sufferers,  for  whom  it  has  an  easy  and  effectual 
relief,  would  eagerly  avail  themselves  of  its  help. 

To  some  the  practice  of  hypnotism  is  objectionable, 
because  there  are  many  charlatans  who  employ  it  or  adver- 
tise to  do  so.  Those  who  argue  thus,  to  be  consistent  and 
logical,  should  abandon  the  use  of  all  medicines,  all  hygienic 
measures,  everything,  indeed,  by  which  they  try  to  affect 
their  patients,  for  there  is  nothing  that  the  quacks  do  not 
exploit.  One  can  hardly  look  at  a  daily  paper  or  a  popular 
magazine  without  having  forced  upon  his  attention  some 
flamboyant  announcement  of  a  drug,  a  method  of  exercise, 
a  kind  of  battery,  a  drink,  a  food  —  something  presented 
with  an  attractive  picture  and  an  adroitly  worded  statement, 
which,  it  is  promised,  will  positively  put  disease  to  flight, 
prolong  life  to  the  ripest  old  age,  and  supplant  misery  with 
exuberant  happiness.  But  none  of  us  are  so  disgusted  with 
these  mendacious  advertisements  that  we  think  it  necessary 
to  throw  away  the  pharmacopeia,  cease  to  recommend 
physical  culture,  give  up  electricity,  forbid  the  use  of  ali- 
mentary remedies.  We  continue  to  employ  whatever  means 
we  think  will  benefit  those  persons  who  honor  us  with  their 


The  Therapeutic  Value  of  Hypnotic  Suggestion         69 

confidence  by  seeking  our  advice  and  skill.  Why,  then, 
should  we  select  one  particular  kind  of  agent,  and  avoid  it 
on  the  ground  that  it  is  used  by  pretenders  ?  The  breadth 
of  mind  which  we  like  to  believe  characterizes  our  profession 
should  enable  us  to  welcome  any  agency,  whatever  its  origin, 
however  unwisely  or  dishonestly  it  is  used  by  others,  what- 
ever compromising  associations  it  has  previously  had,  pro- 
vided only  that  it  will  enable  us  more  readily,  more  agreeably, 
more  perfectly,  to  diminish  suffering,  prevent  disease,  or 
restore  health.  Therefore,  when  one  hears  hypnotism 
likened  to  any  of  the  popular  mind-cure  movements,  which 
to  his  trained  intellect  are  manifestly  unscientific  and  illog- 
ical, let  him  ascribe  the  statement  to  ignorance,  and  enter 
upon  the  investigation  of  this  form  of  psychotherapy  with 
confidence  that  the  more  he  learns  about  it  the  greater  will 
be  his  respect  for  it. 

It  has  been  alleged  that  a  belief  in  the  remedial  virtues 
of  hypnotism  would  do  away  with  the  necessity  for  diagnosis. 
Nothing  could  be  wider  of  the  mark.  The  physician  who 
includes  this  agency  in  his  armamentarium  does  not  change 
his  attitude  toward  pathology,  etiology,  or  physical  diagnosis. 
He  sees,  as  plainly  as  one  can,  that  the  first  thing  is  to  find 
out  what  is  the  matter,  to  ascertain  the  character  of  the 
malady,  and  he  does  not  use  hypnotic  means  in  treatment 
unless  his  investigation  persuades  him  that  the  trouble  is  of 
a  kind  to  which  this  remedy  is  scientifically  applicable. 

One  of  the  commonest  criticisms  of  hypnotism  is  to  the 
effect  that  the  ailments  which  it  relieves  are  all  imaginary. 
If  a  patient  is  said  to  have  been  freed  from  pain,  some  astute 
skeptic  asks,  "  Was  the  pain  real  ?  "  To  such  the  answer 
should  be:  *  When  a  patient  comes  to  you  complaining  of 
pain,  do  you  distrust  his  word  ?  After  he  has  taken  the 
anodyne  which  you  administer,  and  declares  to  you  that  his 
pain  has  disappeared,  do  you  question  his  veracity  ?  You 
cannot  prove  by  the  evidence  of  any  or  all  of  your  senses 


"jo  Psychotherapeutics 

that  either  statement  was  true  or  false,  for  his  symptom  is 
absolutely  subjective.  But  you  do  know  your  patient,  and 
have  no  reason  to  doubt  his  truthfulness  in  this  matter  any 
more  than  in  any  other;  and  so  you  do  not  hesitate  to  give 
him  the  remedy  that  your  experience  has  taught  you  is  suit- 
able to  his  condition.  Now,  suppose  such  a  patient  is  treated 
with  hypnotic  suggestion,  and  the  suffering  is  promptly 
abolished,  is  there  any  sense,  reason,  or  fairness  in  thinking 
that  his  pain  was  imaginary,  and  not  as  real  as  that  which 
was  relieved  by  your  drug  ?  " 

It  has  been  charged  that  hypnotism  is  not  scientific; 
but  it  is  difficult  to  perceive  upon  what  ground  this  opinion 
is  based.  Tested  by  any  of  the  rules  which  we  apply  to  the 
remedies  which  we  all  employ  it  is  not  found  wanting;  and 
it  is  not  just  to  subject  it  to  severer  tests  than  we  think  suffi- 
cient for  all  the  others.  If  it  is  objected  that  we  do  not  know 
the  mental  mechanism  by  which  hypnosis  is  induced,  it  is 
fair  to  remind  the  critic  that  he  cannot  explain  the  mechanism 
of  memory,  a  fundamental  and  comparatively  simple  intel- 
lectual process.  If  it  is  alleged  that  there  is  a  large  empirical 
element  in  hypnotic  treatment,  it  is  proper  to  ask  if,  in  this 
respect,  it  is  on  a  lower  plane  than  our  usual  method  of  using 
drugs. 

It  has  been  alleged  that  the  therapeutic  effects  of  hyp- 
notic suggestion  are  but  transient:  that,  if  any  benefit  results 
from  it,  in  a  short  time  the  patient  will  relapse  into  his 
former  condition.  Nobody  acquainted  with  the  facts  could 
possibly  make  this  criticism.  The  effects  of  no  remedy,  with 
which  a  comparison  can  fairly  be  made,  are  more  enduring 
than  are  those  of  hypnotic  suggestion. 

Equally  inapplicable  is  the  comment  that  groups  hyp- 
notism with  methods  of  treatment  in  which  prominence  is 
given  to  a  mystical  element,  which  appeal  to  the  supersti- 
tious, which  associate  theology  and  therapeutics,  which 
demand  faith  in  a  dogma.  The  psychology  on  which  hyp- 


The  Therapeutic  Value  of  Hypnotic  Suggestion        71 

notic  suggestion  is  based  is  as  far  removed  from  mysticism 
or  religion  in  any  form  as  is  physiology  —  indeed,  it  may  be 
said  to  be  physiology  applied  to  mental  processes.  The 
hypnotist  is  not  spiritistic  in  any  sense  of  the  word;  he  asks 
his  patient  for  no  faith,  save  that  which  every  physician  has 
a  right  to  expect  in  any  person  who  confides  health  and  life 
and  reputation  to  his  care.  In  treatment  by  any  method 
it  is  universally  recognized  that  confidence  in  an  expected, 
or  even  hoped  for,  result  is  a  helpful  factor.  No  well- 
informed  person  that  doubts  that  wonderful  cures  are  some- 
times wrought  under  the  ministrations  of  the  most  dishonest 
charlatans,  as  the  result  of  religious  exaltation,  in  conse- 
quence of  absorbing  belief  in  absolutely  senseless  doctrines; 
and  he  knows,  too,  that  these  beneficent  effects  are  as  abun- 
dantly manifested  among  the  worshippers  of  idols  and  the 
practisers  of  obscene  and  degrading  rites  as  among  the 
people  of  his  own  creed.  That  expectation  is  desirable  in 
hypnotic  treatment,  as  in  any  other,  must  be  manifest;  but 
in  none  is  it  less  essential.  Particularly  may  it  be  insisted 
that  in  hypnotism  there  is  no  occult  or  esoteric  element, 
there  is  nothing  to  conceal,  there  is  no  desire  to  take  advantage 
of  credulity,  or  to  play  upon  the  confiding  nature  of  the  igno- 
rant and  superstitious. 

That  hypnotism  is  often  but  little  understood  by  men 
to  whom  the  profession  has  a  right  to  look  for  enlightenment 
in  such  matters  is  frequently  demonstrated.  Some  of  the 
high  priests  of  neurology  are  the  greatest  sinners  in  this 
direction;  but  none,  probably,  have  displayed  their  incompe- 
tency  and  ignorance  quite  as  conspicuously  as  has  Dubois, 
the  author  of  a  book  on  the  psychic  treatment  of  nervous 
disorders.  This  has  been  translated  into  English  and  has 
evidently  deeply  influenced  many  physicians  and  awakened 
a  wholesome  interest  in  a  certain  form  of  psychotherapy. 
His  treatment  by  persuasion  has  undoubted  merit,  though 
little  novelty;  but  it  is  pitiful  that  he  should  assume  the  atti- 


72  Psychotherapeutics 

tude  which  he  does  toward  hypnotism  —  an  attitude  which 
reveals  at  once  ignorance,  narrowness,  prejudice,  and  incon- 
sistency. He  girds  at  hypnotism,  at  every  opportunity,  he 
holds  it  up  to  ridicule  and  contempt;  and  yet  he  admits  that, 
on  occasion,  he  uses  it,  as  he  certainly  should  not,  if  it  is  the 
evil  thing  that  he  would  have  us  believe.  In  doing  this  he 
unconsciously  pays  it  the  highest  tribute.  Let  me  quote  a 
passage: 

'  This  is  one  of  those  exceptional  cases  where  I  would 
not  fear  to  have  recourse  to  hypnosis,  althought  he  attitude  of 
the  wonder-worker  that  one  has  to  take  is  so  repugnant  to  me 
that  it  brings  a  blush  to  my  cheeks  when  I  decide  to  use  it." 

'  Wonder-working  "  to  him  evidently  means  rapidity 
of  effect,  for  in  another  paragraph  he  says: 

'  The  practice  of  hypnosis  has  accustomed  one  to  im- 
mediate success,  to  theatrical  effects." 

Are  we  to  refrain  from  employing  any  method  because 
its  results  are  prompt  ?  We  have  been  accustomed  to  con- 
sider speed  in  attaining  a  desired  end  a  decided  merit.  The 
motto  on  the  seal  of  this  society,  "  Curare  cito,  tuto,  et 
juncude,"  which  we  adopt  from  the  ancient  Asclepiades, 
is  universally  acclaimed  as  the  ideal  rule  of  action;  and 
hypnotism  fulfils  all  of  these  conditions,  for  it  does  cure 
quickly,  safely,  and  pleasantly.  Apply  the  objection  to 
another  class  of  cases:  a  patient  comes  to  a  physician  with 
a  chronic  irritative  cough.  Examination  reveals  a  relaxed 
uvula  dangling  onto  the  tongue  and  constantly  tickling  the 
pharynx.  Does  anybody  advocate  the  cutting  off  of  the 
sixteenth  of  an  inch  a  day  for  the  sake  of  avoiding  the  sud- 
denness of  cure  effected  by  complete  ablation  ?  But  the 
method  by  which  instant  and  permanent  relief  is  afforded 
is  open  to  the  criticism  of  being  theatrical.  Dubois  objects 
to  "wonder-working,"  if  the  quick  cure  is  brought  about  by 
hypnosis,  as  if  one  appealed  to  the  thaumaturgy  of  the 
ancient  magicians;  and  yet  he  says : 


The  Therapeutic  Value  of  Hypnotic  Suggestion        73 

"  The  art  of  the  physician  lies  just  in  choosing  in  each 
case  the  most  rapid  and  powerful  means  of  improvement." 

Can  inconsistency  go  further  ?  If  his  vaunted  method 
achieves  an  immediate  result,  it  is  praiseworthy;  but,  if 
hypnotism  does  the  same  thing,  it  is  damnable. 

To  show  how  utterly  ignorant  of  the  principles  of  hyp- 
notic treatment  this  author  is,  one  more  sentence  may  be 
quoted :  '  What  is  more  absurd  than  to  fall  asleep  by 
daylight,  when  one  has  no  need  of  sleep,  by  stupidly  yielding 
to  the  command  of  the  hypnotizer  ?  " 

It  seems  almost  incredible  that  a  physician  who  poses 
as  a  neurologist  and  a  psychotherapist,  should  not  know  that 
the  purpose  of  the  hypnotizer  in  inducing  the  sleep  is  solely 
to  put  the  patient  into  a  more  suggestible  condition.  When 
a  man  of  the  eminence  of  Dubois  is  capable  of  so  humiliating 
an  exhibition  as  this,  we  may  look  with  more  charity  and 
patience  upon  the  men  who  constitute  the  rank  and  file  of 
the  profession,  when  they,  as  a  result  of  dense  ignorance, 
declare  hypnotism  to  be  dangerous,  foolish,  quackish, 
fraudulent,  necromantic,  and  altogether  unjustifiable. 

It  ought  to  be  unnecessary  to  say  that  the  employment  of 
any  form  of  psychotherapy  is  not  incompatible  with  the  use 
of  physical  agents  of  any  description.  In  many  cases  it  is 
important  to  associate  different  kinds  of  therapeutic  agents, 
which  are  not  psychic,  as  we  all  know;  the  case  in  which  a 
psychic  method  is  desirable  makes  no  exception.  Psycho- 
therapy should  be  regarded  as  an  additional  means  of  promot- 
ing the  welfare  of  the  patient,  whatever  other  kind  of  treat- 
ment has  been  instituted. 

In  this  essay  I  have  not  attempted  an  exhaustive  treat- 
ment of  my  subject,  but  I  have  tried  to  show  as  well  as  pos- 
sible in  the  time  allowed  what  hypnotism  is,  and  what  can 
be  done  with  it  by  any  well-educated,  competent  physician 
for  the  benefit  of  the  sick  and  suffering;  and,  finally,  I  have 
endeavored  to  make  it  clear  that  the  objections  to  its  use 


74  Psychotherapeutics 

are  not  based  upon  knowledge,  but  upon  ignorance  and 
prejudice.  The  points  touched  upon  are  those  about  which 
questions  are  most  frequently  asked  or  adverse  criticism 
made,  and  the  answers  and  explanations  are  founded  upon 
a  large  observation  of  the  practical  workings  of  the  method. 
I  have  no  expectation  of  effecting  a  wholesale  conversion 
of  opponents  to  these  views  —  I  know  too  well  the  ingrained 
conservatism  of  our  profession  regarding  psychic  remedies; 
but  I  entertain  a  little  hope  that  what  I  have  said  will  arouse 
in  some  minds  an  intelligent  interest  in  the  subject;  and  I 
am  confident  that  no  open-minded  physician  can  look  into 
it  fairly,  as  he  would  into  any  other  therapeutic  method, 
without  being  persuaded  that  in  hypnotic  suggestion  are  possi- 
bilities for  good,  which  our  profession  should  no  longer  neglect. 


SIMPLE  EXPLANATION  AND  RE-EDUCATION 
AS  A  THERAPEUTIC  METHOD 

BY  E.  W.  TAYLOR,  M.D.,  BOSTON 

Instructor  in  Neurology,  Harvard  Medical  School;  Assistant 

Physician  Department  of  Neurology,  Massachusetts 

General  Hospital;     Visiting  Neurologist, 

Long  Island  Hospital,  Boston. 


SIMPLE   EXPLANATION  AND  RE-EDUCATION 
AS  A  THERAPEUTIC  METHOD 

TWO  difficulties  are  evident  in  the  present  aim  to 
rationalize  psychotherapeutic  procedure.  One  is 
its  supposed  simplicity  and  the  other  its  reputed 
complexity.  A  very  considerable  group  of  men 
in  the  medical  profession  apparently  considers  that  nothing 
new  has  been  discovered  within  the  past  few  years  relative 
to  the  treatment  of  disease  by  mental  means.  Another 
group  is  equally  insistent  that  the  whole  subject  constitutes 
a  special  branch  of  medicine  and  is  quite  beyond  the  practical 
reach  of  the  general  practitioner.  Both  of  these  positions 
are  wrong.  In  the  first  place,  it  is  apparent  that  the  investi- 
gation of  recent  years  has  so  far  rationalized  old  methods 
that  the  physician  now  has  in  his  hands  a  perfectly  definite 
means  of  attack  against  many  abnormal  and  distressing 
conditions.  However  widely  psychotherapeutic  measures 
have  been  practised  from  the  earliest  period  of  medicine, 
the  time  has  now  come  when  such  measures  may  be  used 
with  a  degree  of  scientific  accuracy  hitherto  unattained,  a 
precisely  similar  situation  to  that  prevailing  in  all  other 
departments  of  therapeutics.  The  means  of  treatment  have 
always  been  at  hand.  The  use  to  which  those  means  are  put 
constitutes  advance.  On  the  other  hand,  it  is  true  that  the 
final  solution  of  the  complex  problems  upon  which  we  have 
now  entered  is  no  doubt  far  distant,  and  the  pioneer  work  in 
this  somewhat  limitless  field  must  be  left  to  the  special 
student.  There  is,  however,  no  longer  a  question  that 
sufficient  facts  have  been  established  to  render  certain  of 
these  therapeutic  measures  available  for  the  practitioner. 
Here  again  the  situation  is  not  different  from  that  of  other 
departments  of  medicine.  The  problem  of  immunity,  for 
example,  remains  obscure,  and  in  great  measure  unsolved, 

77 


78  Psychotherapeutics 

but  the  practical  applications  of  this  laborious  work  are  al- 
ready in  a  measure  available. 

It  should  in  general  be  our  aim  to  place  this  whole  much 
discussed  question  of  psychotherapeutics  on  precisely  the 
same  plane  as  other  therapeutic  problems.  So  far  as  facts 
are  ascertained  and  capable  of  practical  application,  it  is  the 
manifest  duty  of  practitioners  to  employ  such  facts  for  the 
benefit  of  their  patients.  So  far  as  facts  are  still  in  doubt 
it  is  the  natural  work  of  special  students  of  the  subject  to 
bring  what  order  is  possible  out  of  the  existing  chaos.  Our 
methods  of  procedure  should  be  the  same,  so  far  as  the  char- 
acter of  the  subject  permits,  our  results  should  be  subjected 
to  the  same  strict  scientific  judgment,  and  our  liberality 
toward  this  branch  of  therapeutics  should  be  precisely  similar 
to  that  toward  any  other  which  promises  much  for  the  future. 

The  object  of  this  symposium,  so  far  as  I  understand  it, 
is  for  the  time  being  to  lay  aside  theoretical  considerations 
and  to  bring  to  the  attention  of  this  society  such  facts  and 
practical  considerations  as  the  time  at  our  disposal  and  our 
individual  experience  permit.  It  is  my  purpose  in  what 
I  shall  have  to  say  under  the  somewhat  inadequate  title 
selected  to  draw  attention  to  the  simplest  and  therefore  most 
widely  available  method  of  psychotherapeutic  procedure 
and  to  attempt  to  show  how  such  a  method  may  be  made 
practically  useful  by  the  physician  in  a  degree  hitherto  not 
always  attained. 

In  discussing  the  general  psychotherapeutic  problem 
with  physicians,  the  purely  practical  question  of  method  is 
almost  invariably  raised.  What  the  practitioner  needs  and 
rightly  demands  from  those  who  claim  any  special  knowl- 
edge of  the  subject  are  directions  as  to  treatment  of  individual 
patients.  The  evident  difficulty  heretofore  in  treating  even 
the  simple  neuroses  has  been  the  failure  on  the  part  of  physi- 
cians to  recognize  clearly  that  such  neuroses  very  frequently 
have  a  mental  cause  in  the  life  of  the  individual  precisely  as 


Re-education  as  a  Therapeutic  Method  79 

a  murmur  over  the  heart  area,  for  example,  has  a  physical 
cause  in  the  life  of  the  individual.  Our  first  object  as  prac- 
titioners is  the  determination  so  far  as  lies  in  our  power  of 
the  exact  cause  of  the  condition  we  are  called  upon  to  treat. 
In  other  words,  a  diagnosis  is  demanded.  This  we  make 
readily  enough  in  the  physical  sphere  or  admit  our  incapacity 
to  do  so.  In  the  mental  sphere,  we  too  often  make  no 
attempt,  however  apparent  the  cause  might  be  after  ade- 
quate investigation.  The  first  point,  therefore,  I  would 
make  is  that  we  must  be  as  conscientious  in  one  field  of 
medicine  as  in  another.  We  must  search  the  mind  of  the 
individual  for  the  source  of  his  discomfort  in  appropriate 
cases  in  exactly  the  same  spirit  in  which  we  search  his  body 
for  the  source  of  other  discomforts.  This  certainly  requires 
no  special  personal  attributes  on  the  part  of  the  physician, 
and  is  surely  available  for  practitioners  of  no  special  educa- 
tion in  this  field.  The  word  "  explanation  "  used  in  the 
title  describes  somewhat  inadequately  the  actual  procedure, 
which  consists  essentially  in  the  following  steps : 

First.  After  eliminating  or  properly  estimating  physical 
causes  the  mental  attitude  of  the  patient  toward  his  ailment 
should  be  carefully  determined;  in  other  words,  a  diagnosis 
should  be  made. 

Second.  This  is  best  accomplished  by  allowing  him  to 
tell  his  complete  story  rather  than  by  a  primary  process  of 
interrogation  on  the  part  of  the  physician. 

Third.  Having  determined  the  false  point  of  view 
almost  invariably  revealed  which  has  led  up  to  the  neurosis 
the  attempt  is  made  to  explain  why  such  a  series  of  events  as 
that  disclosed  would  be  likely  to  lead  to  this  result. 

Fourth.  Having  impressed  the  patient  with  the  correct- 
ness of  the  physician's  point  of  view  the  process  of  readjust- 
ment begins,  or,  to  use  the  more  popular  but  possibly  too 
comprehensive  term,  his  re-education. 


80  Psychotherapeutics 

Fifth.  This  is  accomplished  by  pointing  out  in  a  pains- 
taking way  the  correct  way  to  mental  health  through  a  real- 
ization on  the  part  of  the  patient  of  his  previous  miscon- 
ceptions and  through  an  accompanying  effort  toward  the 
establishment  of  more  rational  mental  adjustments. 

The  method  outlined  above  is  the  simplest  possible 
psychotherapeutic  procedure.  As  in  more  complex  methods 
described  by  other  writers  in  this  symposium  its  essential 
feature  is  the  analysis  of  the  mental  state.  Its  value  lies  in 
its  simplicity  and  in  its  appeal  to  the  reason  through  the 
medium  of  commonsense.  We  are  justified  in  calling  it  a 
method  because  it  works  in  practice,  when  mere  unmethodi- 
cal encouragement  and  reassurance  fail.  That  such  a 
method  stripped  as  it  is  of  all  appeal  to  the  mysterious  or  to 
any  form  of  sensationalism  is  capable  of  wide  and  legitimate 
application  is  self-evident.  It  is  also  apparent  that  it  must 
often  prove  unsuccessful  in  those  cases  in  which  the  course 
of  a  developed  neurosis  is  so  deeply  buried  in  the  past  life  of 
the  individual  that  it  cannot  be  brought  to  the  surface  by 
this  simplest  and  in  one  sense  most  superficial  of  the  analytic 
methods. 

It  may  with  truth  be  said  that  no  person  is  wholly  free 
from  false  conceptions  of  his  own  mental  and  physical  condi- 
tion, and  this  naturally  applies  to  those  who  consult  physi- 
cians in  the  most  varied  fields  of  practice.  It  is  an  error  to 
stigmatize  such  persons  forthwith  as  abnormal  or  neurotic 
or  neurasthenic  or  psychasthenic.  Many  of  the  common 
neuroses  met  with  in  practice  represent  nothing  more  than 
aberrations  of  normal  nervous  systems  into  temporary  use- 
less or  detrimental  channels.  As  a  matter  of  fact,  a  large 
proportion  of  so-called  nervous  invalids  are  incapacitated 
through  no  inherent  fault  of  their  nervous  systems  as  such, 
but  rather  through  the  use  to  which  their  nervous  systems  have 
been  put  by  circumstances  or  training  or  false  instruction 
or  unwise  and  superficial  medical  advice. 


Re-education  as  a  Therapeutic  Method  81 

Quite  apart  from  any  psychophysical  speculation  as  to 
the  relation  between  the  mind  and  the  body  which  is  wholly 
unessential  from  a  practical  standpoint,  the  clear  recogni- 
tion of  the  predominant  mental  origin  of  the  neuroses, 
whether  or  not  they  have  accompanying  physical  manifesta- 
tions is  of  the  utmost  importance  and  unquestionably  con- 
stitutes the  essential  advance  of  recent  years  in  their  intelli- 
gent treatment.  We  have  gained  much,  if,  for  example,  we 
may  authoritatively  tell  our  patients  that  their  apparently 
disordered  nervous  symptoms  have  reacted  in  a  perfectly 
normal  way  to  the  circumstances  in  which  they  have  been 
placed,  and  to  the  ideas  to  which  they  have  been  exposed,  and 
that  their  difficulties  have  been  due  to  the  character  of  these 
ideas  and  circumstances  rather  than  to  the  much  feared 
inherent  weakness  of  the  nervous  system  itself.  The 
function  of  the  physician  at  once  becomes  apparent.  He 
hears  the  story,  he  sees  wherein  the  individual  has  failed, 
wherein  he  has  dissipated  his  energies  in  side  issues,  or,  in 
popular  parlance,  wasted  his  opportunities.  Out  of  this  he 
recognizes  that  a  so-called  neurosis  has  developed  which 
it  becomes  his  task  to  diagnosticate  accurately,  to  explain 
in  an  understandable  way  the  steps  by  which  he  has  arrived 
at  his  diagnosis,  and  to  readjust  the  patient's  mental  attitude 
on  the  basis  of  this  knowledge. 

In  order  to  avoid  any  possibility  of  confusion  I  have 
used  the  word  "  explanation  "  to  describe  this  rational 
process.  It  requires  little  actual  experience  to  demonstrate 
that  in  order  to  explain  these  matters  effectively  to  our 
patients  we  must  follow  some  definite  method.  Otherwise, 
as  in  other  departments  of  endeavor,  we  shall  simply  confuse 
and  not  benefit.  It  is  furthermore  imperative,  with  all  the 
present  day  talk  in  the  popular  press  as  well  as  in  medical 
literature  regarding  treatment  by  mental  means,  that  we 
adopt  a  definite,  commonsense  basis  of  procedure,  free  from 
all  subtlety  or  demand  for  highly  specialized  training. 


82  Psychotherapeutics 

From  the  foregoing  discussion  I  wish  to  emphasize  the 
following  points:  First,  the  wide  prevalence  of  neuroses 
based  on  ignorance  rather  than  inherent  or  acquired  weak 
nervous  organization.  Secondly,  the  vital  importance  of 
recognizing  the  normal  character  of  the  nervous  systems  in 
which  these  neuroses  have  developed.  Thirdly,  the  possi- 
bility as  a  rational  means  of  treatment  of  explaining  to  an 
intelligent  patient  the  mechanism  of  the  development  of  his 
symptoms,  and  finally  the  probability  of  a  readjustment  of 
his  mental  state  based  on  this  explanation  with  the  disap- 
pearance of  the  neurosis.  The  analogy  of  the  mental  state 
of  the  child  is  useful  in  this  connection.  Explanation  forms 
the  chief  means  of  increasing  a  child's  mental  stability.  Fear 
of  the  dark,  to  take  a  commonplace  example,  is  not  met  on 
the  part  of  the  wise  parent  by  harsh  criticism  and  summary 
dismissal  of  the  subject,  but  rather  by  explanation  suited  to 
the  child's  comprehension  that  the  dark  in  reality  has  no 
terrors,  and  by  a  demonstration  of  the  truth  of  this  fact. 
Similar  fears  in  adult  life  are  manifestly  treated  with  far  less 
consideration;  on  the  part  of  the  patient  there  is  a  tendency 
toward  concealment  of  special  anxieties,  on  the  part  of  the 
physician  there  is  often  a  wholly  unsympathetic  attitude 
in  which  explanation  plays  no  part.  The  position  of  the 
adult  is,  however,  precisely  analogous  to  that  of  the  child. 
Neither  is  the  victim  of  disease  or  necessarily  possesses  a 
damaged  nervous  system.  Both  are  victims  of  insufficient 
knowledge  and  both  demand  sympathetic  explanation  in 
order  that  their  false  points  of  view  may  be  corrected.  Both 
are  real  and  often  extreme  sufferers  from  conditions  which 
are  not  self-limited,  but  which  tend  to  progress  and  become 
more  complex  in  their  organization.  Our  attitude  toward 
children  has  on  the  whole  been  correct;  our  error  has  been 
the  failure  to  realize  that  wisdom  does  not  necessarily  come 
with  the  years. 

Examples  may  make  this  clearer.  A  patient  consults 
a  physician  in  a  highly  disturbed  nervous  state  popularly 


Re-education  as  a  'Therapeutic  Method  83 

known  as  neurasthenic.  The  analysis  of  the  entire  situa- 
tion reveals  the  fact  that  this  patient  considers  that  he  has 
lost  his  memory.  He  has  arrived  at  this  conclusion  because 
he  finds  that  he  is  no  longer  able  to  read  attentively  and 
remember  what  he  has  read.  From  this  as  a  starting  point 
he  argues,  legitimately  enough  from  his  knowledge,  as 
follows:  I  cannot  remember  what  I  have  read;  my  memory 
must  therefore  be  weakened;  memory  is  a  fundamental 
quality  of  the  normal  mind;  my  mind  therefore  must  be 
failing,  and  forthwith  one  of  the  commonest  and  most  dis- 
tressing and  incapacitating  phobias  is  developed,  namely, 
the  imminent  fear  of  insanity.  In  such  a  commonplace 
instance  as  this  it  is  clear  that  the  patient's  mind  has  worked 
out  a  rational  conclusion  from  false  premises,  the  original 
false  premise  being  that  because  he  could  not  remember 
what  he  read,  therefore  his  mind  was  failing.  It  is  easy  to 
set  such  a  person  right  by  the  simple  explanation  that  his 
original  difficulty  arose  from  lack  of  concentration,  a  common 
human  weakness,  and  that  out  of  such  lack  of  concentration 
the  mental  alienation  which  he  feared  is  extremely  unlikely 
to  develop.  This  rational  point  of  view  is  on  the  whole  easy 
to  impress,  and  its  result  on  the  developed  neurosis  with  its 
various  accompanying  manifestations  of  sleeplessness,  anx- 
iety, incapacity  for  work,  loss  of  appetite,  and  all  the  other 
phenomena  of  a  disturbed  mental  state,  forthwith  becomes 
apparent.  The  essence  of  the  benefit  in  such  a  case  is  to  be 
attributed  purely  to  a  reasonable  explanation  of  a  series  of 
events  which  the  patient  has  himself  been  unable  to  estimate 
properly. 

A  further  example  illustrative  of  the  point  of  view  I  am 
attempting  to  impress  is  the  mental  condition  ordinarily 
associated  with  insomnia.  There  is  a  deeply  rooted  feeling 
in  the  popular  mind  that  sleep  is  an  absolute  essential  to 
continued  mental  health  and  conversely  that  deprivation  of 
sleep  is  a  direct  sign  of  both  physical  and  mental  breakdown. 


84  Psychotherapeutics 

Assuming  this  statement  to  be  correct  the  ordinary  person 
finds  himself  in  a  state  of  extreme  anxiety  when  for  any  reason 
his  sleep  is  interfered  with.  The  result  of  this  anxiety  very 
naturally  is  such  a  fixation  of  the  attention  upon  his  physical 
and  mental  condition  that  sleep  for  this  very  reason  becomes 
increasingly  difficult.  Thus,  the  ordinary  vicious  circle  is 
formed.  I  have  in  mind  a  patient,  a  middle-aged  man  of 
active  business  interests,  who  was  so  strongly  impressed  with 
the  idea  that  without  sleep  he  must  necessarily  go  to  pieces, 
that  his  life  was  becoming  a  burden  to  himself  and  to  his 
friends.  Reasoning  from  his  premises,  he  assumed  that 
inasmuch  as  sleep  was  essential  to  continued  health  and  he 
was  certainly  not  having  a  normal  amount  of  sleep,  he 
could  not  continue  well.  The  treatment  of  this  situation 
stated  in  barest  outline  was  in  the  first  place  to  explain  that 
he  had  a  wrong  conception  of  the  significance  of  sleep,  that 
complete  physical  and  mental  rest  without  sleep  would  suffice 
to  restore  him  for  the  work  of  the  succeeding  day,  and  finally 
that  could  he  compose  himself  to  such  complete  physical 
and  mental  rest,  sleep  would  naturally  follow.  This,  as  a 
matter  of  fact,  is  what  actually  happened.  The  cause  of  the 
sleeplessness  in  this  instance  was  essentially  the  mental  state 
induced  by  the  fear  that  he  would  not  sleep.  A  more  striking 
instance  is  that  of  a  man  from  the  Provinces,  also  of  middle 
age,  who  for  some  six  years  had  been  unable  to  sleep  and  had 
developed  various  so-called  neurotic  symptoms  as  he  sup- 
posed in  consequence  of  this  sleeplessness.  The  origin  of 
his  difficulty  he  definitely  attributed  to  a  single  occasion 
when  he  had  more  or  less  voluntarily  remained  awake 
practically  all  night  in  anticipation  of  a  very  early  morning 
journey.  From  this  simple  and  commonplace  event,  the 
habit  of  sleeplessness  apparently  was  formed,  and  from  that 
time  to  this  it  has  been  kept  alive  evidently  by  the  anxiety 
which  has  developed  in  consequence  of  his  conception  of  the 
necessity  of  sleep,  precisely  similar  to  the  case  just  cited. 


Re-education  as  a  Therapeutic  Method  85 

Here  also  it  was  not  difficult,  after  three  or  four  interviews 
in  which  explanation  alone  was  used,  to  show  the  patient 
wherein  his  knowledge  had  been  deficient  regarding  various 
physiological  processes  connected  with  sleep  and  to  make 
clear  to  him  the  pernicious  part  his  faulty  mental  attitude 
had  played  in  the  development  of  his  neurosis.  The  patient 
was  easily  relieved  of  his  difficulty,  at  least  until  he  left  Boston 
to  return  home.  I  have  not  heard  from  him  since. 

It  would  be  easy  to  multiply  cases  of  this  sort,  illustrative 
of  the  part  which  incorrect  deductions  play  in  the  develop- 
ment of  most  varied  neurotic  conditions.  The  foregoing 
instances,  however,  may  suffice  to  illustrate  in  simplest  form 
the  principle  underlying  this  method  of  psychotherapeutic 
procedure. 

The  possibilities  and  limitations  of  the  method  I  have 
attempted  to  outline  may  be  summarized  but  not  detailed 
in  so  brief  a  communication  as  this.  Its  possibilities  are 
that  it  may  be  used  by  any  intelligent  physician  who  realizes 
its  importance;  the  personality  of  the  physician  about  which 
we  still  continue  to  hear  plays  a  small  part  in  its  success.  It 
requires  no  special  training,  psychological  or  otherwise, 
beyond  that  which  every  educated  physician  might  easily 
acquire.  It  is  not  limited  to  the  treatment  of  so-called 
"  nervous  "  cases.  It  should,  for  example,  be  applied  ante- 
cedent to  surgical  operations,  particularly  on  the  pelvic 
organs  of  women.  It  is  a  commonsense  method  of  ap- 
proach to  many  of  the  minor  ills  and  some  of  the  major  dis- 
orders to  which  all  persons  are  exposed.  It  does  not  demand 
hypnotic  procedure,  or  the  use  of  suggestion  as  that  word  is 
ordinarily  employed.  Its  essential  basis  is  an  appeal  to 
reason  and  herein  naturally  lies  its  wide  applicability.  Its 
limitations  are  no  less  apparent.  It  will  naturally  fail  in  the 
psychoses,  in  hysterical  states  associated  with  fundamental 
disorders  of  personality,  and  in  obsessional  conditions  of  a 
high  degree  of  fixity,  matters  to  which  no  doubt  others  taking 
part  in  this  discussion  will  refer. 

*  «4 


THE  TREATMENT  OF  FATIGUE  STATES 

BY   G.    A.    WATERMAN,    M.D. 

Assistant   in   Neurology  at  the  Harvard   Medical  School. 

Assistant  Neurologist  at  the  Massachusetts  General 

Hospital. 


THE  TREATMENT  OF  FATIGUE  STATES 

TAKING  the  various  forms  of  the  psycho-neuroses 
as  a  group  there  is  no  one  symptom  so  frequently 
encountered   as   that  of  fatigue.     Whether   it   be 
present  early  in  the  course  of  the  disease,  and  seems 
to   be  the   soil   from   which   other   symptoms   develop,    or 
whether  it  makes  a  later  appearance  as  if  in  consequence 
of  the   struggle   against    existing   symptoms,   it   too   often 
presents  a  barrier  to  recovery  which  at  times  seems  unsur- 
mountable.     Any  effort  on  the  part  of  the  patient  to  struggle 
against  this  symptom  so  increases  the  fatigue  as  to  accentuate 
other  symptoms,  and  cause  great  discomfort,  while  on  the 
other  hand  continued  rest  is  courted  in  vain.     In  order  to 
determine  how  this  condition  is  to  be  met,  let  us  turn  our 
attention  to  the  elements  which  go  to  make  up  this  fatigue. 


89 


90  Psychotherapeutics 

I.       PHYSIOLOGICAL  FATIGUE 

That  the  production  of  energy  of  every  sort  is  the  result 
of  a  katabolic  process  in  the  tissue  called  into  activity  is  a 
fact  too  well  established  to  require  discussion,  but  unfortu- 
nately fatigue  cannot  be  explained  on  the  simple  ground  that 
the  consumption  of  muscular  substances  alone  produces 
exhaustion. 

In  addition  to  the  diminished  supply  of  the  substances 
in  the  muscle  necessary  for  the  production  of  energy  which 
results  from  muscular  activity,  we  have  also  to  recognize  the 
role  played  by  the  action  of  the  toxic  products  of  oxidation 
accumulating  in  the  tissue.  The  laboratory  experiment  of 
stimulating  the  isolated  frog's  muscle  until  it  can  perform 
no  more  work,  and  then  flushing  out  its  blood  vessels  with 
normal  salt  solution  to  enable  it  to  again  respond  to  stimula- 
tion, represents  the  normal  physiological  process  constantly 
going  on  in  the  human  organism  during  its  daily  life. 

While  these  two  processes  —  the  combustion  of  sub- 
stances, and  the  local  action  of  the  products  of  katabolism  — 
diminish  the  power  of  the  muscle  to  carry  on  its  function, 
the  liberation  of  the  poisonous  substances  into  the  general 
circulation  gives  rise  to  the  general  sense  of  fatigue  in  the 
individual.  This  has  been  well  shown  by  Mosso,  who 
demonstrated  that  the  introduction  of  the  blood  of  dogs  that 
had  been  tetanized  a  few  minutes,  into  the  cerebral  circula- 
tion of  healthy  dogs,  gave  rise  to  the  signs  of  fatigue  (diffi- 
culty in  breathing,  and  more  rapid  beating  of  the  heart), 
and  Mosso  believes  that  these  noxious  products,  acting  on 
the  nervous  system  through  the  circulation,  not  only  contri- 
bute largely  to  the  feeling  of  fatigue,  but  also  lessen  the  power 
of  the  nerve  cells  to  carry  on  their  function. 

Parallel  to  these  manifestations  of  muscular  activity  is  a 
group  of  physiological  and  histological  changes  taking  place 
in  the  central  nervous  system  as  a  result  of  cerebral  and 


The  Treatment  of  Fatigue  States  91 

reflex  activity.  Hodge  demonstrated  in  1892  that  definite 
changes  are  to  be  found  in  cerebral  and  spinal  ganglion  cells 
of  various  animals  resulting  from  normal  activities  of  daily 
life  as  well  as  from  excessive  stimulation.  He  found  that  a 
comparison  of  nerve  cells  of  animals  killed  in  the  morning 
with  those  of  similar  animals  killed  at  the  close  of  a  day  of 
activity,  showed  a  diminution  in  the  size  of  the  neuclei  with 
loss  of  the  open  reticulate  appearance,  and  shrinkage  in  cell 
protoplasm  with  vacuolation  and  lessened  staining  power. 

That  this  change  in  structure  is  associated  with  libera- 
tion of  harmful  products  has  been  shown  by  Halliburton  in 
his  lecture  on  "The  Chemical  Side  of  Nervous  Activity,"  in 
which  he  maintains  that  under  normal  physiological  condi- 
tions the  injurious  choline  products  of  nerve  katabolism  can 
be  demonstrated  in  the  body,  while  in  states  attended  with 
abnormally  rapid  nerve  degeneration  marked  changes  may 
be  produced. 


92  Psychotherapeutics 


2.      PSYCHOLOGICAL  FATIGUE 

Aside  from  these  physiological  processes  which  contri- 
bute to  make  up  what  may  be  called  physiological  fatigue, 
there  is  a  varying  psychological  factor  which  is  present  in  all 
of  us,  tending  to  accentuate  or  diminish  the  degree  to  which 
it  shall  be  recognized  and  admitted,  whether  consciously  or 
not.  The  power  of  music  to  quicken  the  lagging  steps  of 
tired  soldiers;  the  influence  of  the  emotions  in  redoubling 
one's  strength ;  the  driving  force  of  exhortation  or  promised 
reward,  are  well-known  examples  of  the  way  in  which  the 
feelings  of  fatigue  may  be  dispelled.  Is  it  that  the  marching 
soldier  is  actually  rendered  less  tired  by  the  music,  or  that 
the  threat  or  promise  of  reward  makes  any  change  in  the 
physical  condition  of  the  individual  ?  Such  an  assumption 
would  be  obviously  absurd.  "Ihis  sudden  change  in  the 
feeling  described  involves  what  might  be  termed  the  psycho- 
logical element  in  the  symptom  of  fatigue.  In  the  minds  of 
all  of  us  a  feeling  of  fatigue  indicates  a  call  for  rest  on  the 
part  of  nature.  When  one  begins  to  feel  tired  his  mind  be- 
comes impressed  with  the  fact,  and  the  continued  conscious- 
ness that  this  state  exists  serves  to  intensify  the  sensation  to 
a  greater  or  less  degree,  depending  on  the  suggestibility  of  the 
individual.  A  veritable  fatigue  hyperesthesia  develops. 
In  some  this  psychological  element  may  play  by  far  the  greatest 
part  in  the  production  of  the  symptom,  so  that  the  slightest 
muscular  activity  produces  a  feeling  of  exhaustion  lasting 
for  days,  while  in  others,  determination  of  purpose  or  interest 
in  work  may  engender  a  disregard  or  an  anesthesia  for  the 
symptom  and  thus  enables  them  to  do  tremendous  amounts 
of  work  with  little  discomfort.  It  is  to  this  latter  class  that 
James  refers  in  his  "Energies  of  Men"  in  which  he  describes 
the  process  as  a  breaking  through  the  zone  of  fatigue,  or 
getting  one's  second  wind.  That  the  adoption  of  this  habit 


The  Treatment  of  Fatigue  States  93 

has  its  merits  to  a  certain  extent  in  the  former  class  is  un- 
doubted, but  I  am  convinced  that  it  is  a  dangerous  recom- 
mendation for  the  latter  class,  which  is  naturally  the  one  to 
carry  it  out  most  zealously. 


94  Psychotherapeutics 

3.       PSYCHOPATHOLOGICAL  FATIGUE 

It  is  an  interesting  problem  for  solution  as  to  what  takes 
place  in  those  cases  of  pronounced  fatigue  in  neurotic  individu- 
als, who  at  times  are  so  quickly  relieved  of  the  symptom  by  a 
suggestion,  as  well  as  in  those  who  are  suddenly  overwhelmed 
by  a  sense  of  exhaustion  as  a  result  of  a  nervous  shock  or  a 
fright.  Surely  such  sudden  and  decided  changes  cannot 
permit  an  explanation  on  the  grounds  of  any  of  the  physio- 
logical causative  factors  of  fatigue.  Is  it  not  that  a  synthesis 
takes  place  in  the  former,  and  a  dissociation  in  the  latter, 
much  as  other  manifestations  of  these  processes  may  occur 
under  similar  conditions  ?  The  verification  of  this  hypo- 
thesis might  be  found  in  the  appearance  and  disappearance 
of  fatigue  encountered  in  the  alternations  of  personalities 
described  by  Prince,  Janet,  and  others. 

That  fatigue  states,  whether  physiological,  psychological, 
or  psychopathological,  may  form  a  fertile  soil  for  the  develop- 
ment of  psycho-neurotic  symptoms  is  too  often  demonstrated 
to  us  to  admit  of  question.  In  the  routine  of  daily  life,  if  one 
is  assiduously  devoting  his  energies  to  accomplishing  certain 
ends,  the  rested  individual  who  starts  the  day  presents  a  very 
different  mental  attitude  to  his  surroundings,  to  the  one  who 
returns  home  at  night  weary  from  his  labors.  The  one 
starts  out  fresh  and  vigorous  and  filled  with  the  joy  of  living, 
the  other  too  often  returns  with  slower  step  and  perhaps  with 
tired  or  aching  head,  irritable  to  those  about,  and  critical  of 
things  he  overlooked  so  easily  in  the  morning.  It  requires, 
however,  but  the  reconstructive  power  of  sufficient  nourish- 
ment and  a  good  night's  rest  for  the  pendulum  to  swing  back 
and  establish  the  diurnal  state  of  freshness.  Fortunate  is  he 
who  can  carry  on  his  life  from  day  to  day  unruffled  by  the  stress 
of  extra  burdens  or  the  worry  of  added  cares.  In  those  who 
voluntarily  undertake  excessive  amounts  of  work,  or  who  are 
the  unfortunate  victims  of  the  "  slings  and  arrows  of  out- 


The  Treatment  of  Fatigue  States  95 

rageous  fortune,"  the  periods  of  recuperation  may  not  prove 
sufficient  to  maintain  the  state  of  equilibrium,  and  a  more  or 
less  prolonged  state  of  fatigue  may  result  with  its  various 
concomitant  symptoms. 

Continued  fatigue  with  insufficient  periods  of  rest  may 
develop  in  strong,  healthy  individuals  various  forms  of 
physical  and  mental  symptoms  similar  to  those  seen  in  well- 
defined  neuroses  and  psychoses.  Attention  has  been  called 
to  this  by  Tissie  and  Fere,  and  it  was  well  illustrated  in  the 
condition  developed  in  the  bicycle  riders  of  the  six-day  race 
in  Madison  Square  Gardens  a  few  years  ago.  Various  sorts 
of  delusions  and  hallucinations  were  manifested  by  these  men 
towards  the  close  of  the  race  — the  idea  that  spectators  were 
doing  things  to  prevent  their  winning  led  to  their  repeatedly 
turning  to  escape  imaginary  obstacles,  etc. 

The  ill  effects  of  over  fatigue  from  excessive  muscular 
exercise  are  usually  quickly  recovered  from,  but  the  condi- 
tions resulting  from  prolonged  mental  strain  and  worry  are 
more  liable  to  persist  from  the  very  nature  of  their  cause,  in 
being  more  continuous  and  unremitting.  The  story  is  a 
common  one.  One's  duties  necessitating  mental  applica- 
tion have  been  requiring  too  many  hours;  they  are  not 
dropped  in  the  evening;  sleep  is  more  difficult,  and  the 
diminished  hours  of  recuperation  lessen  the  power  of  appli-  / 
cation;  recognition  of  this  fact  brings  worry  to  the  attack  to 
precipitate  the  uncomfortable  feelings  of  fatigue.  Aside  from 
lassitude  and  loss  of  power  to  concentrate,  the  most  frequent 
symptom  experienced  in  this  state  is  a  sense  of  discomfort 
in  the  head  varying  in  character  and  location.  This  en- 
genders the  idea  that  something  must  be  wrong  within,  and 
too  frequently  suggests  that  insanity  is  imminent,  and  gives 
rise  to  overwhelming  fear  and  constant  introspection,  with  all 
,  its  harmful  influences. 

Distinct  from  the  fatigue  states  of  such  etiology  which 
may  exist  as  a  simple  condition  of  weariness  and  diminished 


96  Psychotherapeutics 

power  of  application,  or  may  present  the  complication  of 
morbid  ideas  developing  from  it,  is  the  state  of  so-called 
"  nervous  exhaustion  "  found  in  individuals  with  a  neurotic 
family  history.  Patients  suffering  from  this  condition  have 
often  experienced  a  series  of  nervous  breakdowns,  and 
never  seem  able  to  struggle  to  the  normal  level.  Such  indi- 
viduals, though  they  present  the  same  symptoms  as  the  class 
described  have  the  psychological  element  of  fatigue  developed 
out  of  all  proportion  to  the  physical,  and  every  attempt  at  a 
departure  from  their  life  of  rest  and  quiet  is  made  under 
protest,  and  with  the  firm  conviction  that  disaster  is  sure 
to  follow. 

That  the  type  of  fatigue  brought  about  by  prolonged 
overwork  or  strain  requires  rest,  relaxation,  and  change  of 
surroundings,  combined  with  advice  best  adapted  to  counter- 
act the  morbid  mental  state  which  may  be  present,  is  appar- 
ent. This  class  comprises  the  cases  which  do  well  by  giving 
up  absolutely  the  sort  of  life  which  has  absorbed  them,  and 
combining  rest  with  activities  of  a  different  nature  which  will 
afford  sufficient  interest  to  divert  the  mind  and  prevent 
reflection. 

The  point  must  be  recognized  and  seized,  however,  when 
this  regime  has  played  its  part,  and  the  time  has  come  for 
putting  the  hand  to  the  plough  again,  for  it  is  all  too  easy  for 
the  memory  of  a  previous  breakdown  and  fear  of  its  recur- 
rence to  render  one  loth  to  resume  his  former  life  again.  It 
is  on  account  of  this  fear  and  hesitation  that  it  is  advisable 
to  keep  in  touch  with  the  patient  and  prevent  backsliding 
until  he  is  well  launched  in  his  old  life. 

The  larger  class  of  patients  so  often  descended  from  neu- 
rotic parents  and  presenting  a  history  of  attacks  of  previous 
nervous  breakdowns,  attempting  again  and  again  to  take 
up  the  duties  of  life,  but  never  seeming  able  to  get  sufficient 
reserve  to  carry  on  the  struggle  for  any  prolonged  period  of 
time,  require  management  of  a  different  sort.  Such  cases, 


The  Treatment  of  Fatigue  States  97 

as  has  been  said,  represent  the  psychological  element  of 
fatigue  in  its  fullest  development.  The  conviction  that 
exhaustion  will  follow  any  amount  of  effort,  physical  or 
mental,  is  already  a  guarantee  that  it  will  result.  On  being 
told  to  do  certain  things  a  patient  recently  remarked,  "  Very 
well,  I'll  do  it,  but  I  know  what  will  happen,  and  you  must 
take  the  consequences."  Of  course  if  she  had  followed 
orders  in  such  a  spirit  the  result  must  have  been  as  she 
determined. 

Frequently  these  patients  have  indulged  in  rest  for 
months,  or  even  years,  without  beneficial  results.  Physically 
sound,  but  unable  to  assume  duties  and  responsibilities  of 
life,  they  form  a  group  too  often  misunderstood,  and  classed 
as  uninteresting  by  the  physician,  yet  woefully  in  need  of 
proper  direction. 

Various  systems  for  the  management  of  this  type  of 
cases  have  been  advanced  by  different  men.  The  earliest 
complete  method  was  that  recommended  by  Dr.  S.  Weir 
Mitchell,  and  has  since  been  referred  to  as  the  rest  cure. 
In  1875  he  published  his  first  paper  treating  of  this  subject 
under  the  title  of  "  Rest  and  the  Treatment  of  Nervous 
Diseases,"  and  a  few  years  later  brought  forth  the  first  edition 
of  his  monograph  "  Fat  and  Blood."  As  is  well  known,  the 
essence  of  his  method  consists  in  pursuing  his  course  along 
certain  definite  lines,  treating  all  cases  alike.  Seclusion, 
rest,  massage,  electricity,  and  feeding  have  been  the  points 
on  which  he  has  laid  particular  stress.  That  he  has  been 
eminently  successful  in  carrying  out  this  method  can  be  at- 
tested by  the  large  number  of  patients  who  have  been  bene- 
fited under  his  care.  That  the  principles  he  employs  exer- 
cise their  results  according  to  his  theories  is,  however,  a 
question.  It  has  been  pointed  out  by  Prince  and  others 
that  the  point  on  which  he  lays  special  stress,  namely  the 
increasing  of  the  body  weight  and  the  production  of  more 
blood,  does  not  by  any  means  lead  to  the  amelioration  of 


98  Psychotherapeutics 

functional  nervous  symptoms;  that  although  change  of  sur- 
roundings may  prove  beneficial  in  many  cases  complete 
isolation  undoubtedly  does  harm  in  certain  types,  and  that 
the  general  result  produced  by  the  completeness  of  the 
regime  owes  its  success  rather  to  the  suggestive  influence 
than  to  any  physical  change  that  takes  place.  This  system 
has  been  more  or  less  widely  adopted  with  modifications  by 
most  of  the  sanitaria  devoted  to  the  treatment  of  nervous 
invalids,  and  the  criticisms  which  may  be  applied  to  this 
method  as  employed  by  its  originator  are  even  truer  here. 
For,  lacking  the  unusual  personality  of  the  father  of  this 
regime,  and  the  confidence  inspired  by  his  continued  suc- 
cesses, the  patient  is  too  ready  to  accept  the  "  rest  cure  " 
as  such,  in  every  sense  of  the  word,  and  thus  derive  from  it 
the  feature  which  should  be  minimized,  while  he  misses  in 
so  doing  the  factor  which  should  be  working  against  his 
psychic  attitude  toward  his  condition. 

Ihis  has  been  so  much  recognized  by  many  of  the  sani- 
taria during  recent  years  that  the  facilities  for  exercise  and 
occupation  have  to  a  large  extent  replaced  those  of  rest  and 
seclusion  with  gratifying  results. 

A  new  impetus  has  been  given  to  the  interest  in  psycho- 
therapeutics  by  the  widespread  reading  of  the  methods  of 
Dubois,  as  set  forth  in  his  book,  "  The  Psychic  Treatment 
of  Nervous  Disorders,"  published  in  1905.  This  method, 
which  has  been  termed  the  system  of  rational  therapeutics, 
has  for  its  aim  the  education  of  the  patient  oftentimes  through 
more  or  less  Spartan  discipline,  and  through  the  presentation 
of  bare  facts  and  truths  regardless  of  the  patient's  attitude 
towards  his  own  condition.  Whereas  the  method  followed 
by  Mitchell  with  its  modifications  as  advocated  by  Dejerine 
and  Barker  have  been  to  rest  and  isolate  the  patient  and 
gradually  win  him  from  his  symptoms  by  education  as  to 
their  nature,  and  encouragement,  meanwhile  treating  the 
various  discomforts  and  increasing  the  patient's  powers  for 


The  Treatment  of  Fatigue  States  99 

activity,  Dubois,  on  the  other  hand,  begins  by  explaining  to 
the  patient  the  actual  condition  of  things,  and  forces  his 
opinion  as  to  the  psychic  nature  of  the  discomfort,  and  re- 
fuses treatment  of  this  by  drugs  or  chemical  means. 
"  Never,"  said  Dubois,  in  discussing  the  use  of  drugs  a  short 
time  ago,  "  will  I  give  a  sleeping  powder  to  a  nervous  patient 
except  in  cases  of  actual  melancholia."  Whether  this 
method  can  be  generally  adopted  by  practitioners  is  a  great 
question.  The  remarkable  personality  of  Dubois,  and  his 
firm  conviction  as  to  the  ethical  and  therapeutic  value  of  his 
method,  render  it  peculiarly  efficient.  It  is  difficult  to  con- 
ceive of  a  patient  not  being  strongly  moved  by  his  remarks, 
which  are  presented  by  him  so  forcibly,  and  clinched  by  his 
frequent  repetition  of  his  favorite  phrase,  "  C'est  la  verite." 

It  is  apparent  that  the  mental  attitude  of  patients 
suffering  from  this  chronic  state  must  be  changed.  New 
groups  of  complexes  must  be  formed.  The  knowledge  that 
experience  has  shown  that  certain  sensations  have  resulted 
from  certain  activities  must  be  replaced  by  a  conviction  that 
these  efforts  may  be  made  without  harm. 

Whether  the  result  may  better  be  brought  about  by  the 
establishment  of  new  complexes  in  the  hypnotic  state,  or  by 
persuasion  and  conviction  established  in  the  waking  state, 
may  be  a  question  in  some  cases.  If  we  are  to  consider  that 
the  unhealthy  complexes  dominant  in  these  cases,  rendering 
them  unable  to  respond  in  a  normal  way  to  their  surround- 
ings, are  to  be  looked  upon  as  a  dissociation,  much  as  moods 
of  depression  are  to  be  regarded,  hypnosis  may  be  offered 
as  a  rational  method  for  establishing  the  normal  state.  Both 
Tuckey  and  Bramwell  have  reported  cases  in  which  the 
fatigue  state  has  been  successfully  treated  in  this  way. 

Personally  I  have  used  the  conversation  method  prac- 
ticed by  Dubois.  Needless  to  say,  the  physical  condition 
must  be  thoroughly  investigated  and  any  deficiences  recog- 
nized, while  it  should  be  assured  that  the  bodily  secretions 
are  functioning  in  a  normal  manner. 


IOO  Psychotherapeutics 

At  the  start,  the  attitude  of  the  patient  toward  his  con- 
dition must  be  changed.  The  discouraged  doldrum  state 
must  be  attacked  by  a  careful  and  truthful  statement  of  the 
existing  condition,  and  the  possibilities  set  forth  which  must 
be  attained,  and  will  result  as  surely  as  the  physical  law  of 
cause  and  effect  is  true.  He  must  regard  his  condition  in  a 
new  light,  and  new  groups  of  complexes  must  be  called  into 
play  and  associated  with  his  individual  symptoms  as  well  as 
with  his  attitude  toward  the  future. 

When  physical  or  mental  effort  is  called  into  play  the 
fatigue  or  discomfort  resulting  should  call  up  the  new  com- 
plexes established,  and  in  order  that  this  may  follow,  the 
association  of  the  new  complex  groups  must  be  more  strongly 
welded  to  the  symptoms  than  are  the  old  groups  of  discour- 
agement, indifference,  fears,  etc.  It  is  here  that  the  mistake 
is  too  frequently  made  of  using  general  unmethodical  encour- 
agement, in  place  of  strengthening  the  association  between 
the  desired  complexes  and  the  tasks  to  be  performed.  This 
is  not  to  be  accomplished  in  a  hasty  consultation,  but  the 
physician  must  spend  sufficient  time  to  feel  himself  thor- 
oughly "  en  rapport "  with  his  patient,  so  that  both  have  a 
tacit  understanding  that  they  are  taking  up  a  task  together 
which  is  going  to  be  accomplished.  Enthusiasm  for  the 
undertaking,  increasing  amounts  of  activity,  and  occupation 
best  suited  to  the  individual,  form  steps  by  which  the  patient 
may  mount  to  his  normal  plane. 

The  rational  acceptance  of  the  feeling  of  fatigue  must  be 
forced  upon  him  until  it  becomes  for  him  a  natural  reflex, 
and  this  carries  him  a  long  way  towards  disregarding  it,  and 
its  final  disappearance.  Frequently  the  patient  remarks, 
'  Yes,  doctor,  I  have  done  as  you  said,  but  I  feel  so  tired." 
11  That  may  be  true,"  is  the  reply,  "but  you  were  just  as  tired 
last  week,  and  then  you  were  accomplishing  nothing.  The 
difference  is,  that  to-day  you  are  so  much  nearer  the  goal." 

I  am  not  in  accord  with  the  belief  of  Dubois  that  abso- 


The  Treatment  of  Fatigue  States  IOI 

lute  disregard  of  all  symptoms  depending  on  the  psychic 
state  should  be  enforced  upon  the  patient.  Certainly  the 
road  is  a  much  easier  one  for  him  to  travel  if  the  distressing 
head  feelings  are  alleviated  by  a  static  current,  or  if  a  gastric 
disorder  is  controlled  by  some  simple  remedy.  The  danger 
is  to  be  avoided  however,  of  too  much  treatment  of  this  sort. 

The  following  cases  are  illustrative  of  the  conditions 
which  may  be  benefited  by  these  methods. 

CASE  I.  This  patient  was  a  student  twenty-one  years  of 
age.  His  father  and  mother  were  both  of  neurotic  families, 
and  were  themselves  subject  to  moods  of  depression,  while  his 
sister  was  of  a  high  strung  and  sensitive  temperament.  The 
patient  had  always  been  strong  and  rugged  physically,  and, 
except  for  certain  disturbing  ideas  in  real  life  such  as  come 
to  imaginative  children,  had  never  had  any  nervous  dis- 
orders. Slow  to  learn,  he  had  found  it  difficult  to  pass  the 
entrance  examinations  to  college,  and  had  some  difficulty 
in  keeping  up  with  his  class  work.  This  was  the  more 
difficult  on  account  of  his  love  of  sports.  His  whole  ambi- 
tion seemed  to  be  to  make  the  'Varsity  team  in  football. 
His  continued  efforts  to  do  well  in  his  studies,  with  his  con- 
stant worry  lest  he  should  not  be  able  to  do  well  in  his 
athletics,  caused  him  toward  the  middle  of  his  first  year  in 
college  to  become  more  and  more  fatigued.  This  sense  of 
weariness  once  started  developed  more  rapidly,  and  made  it 
nearly  impossible  for  him  to  accomplish  any  work.  In  fact, 
so  pronounced  was  the  symptom,  that  repeatedly,  on  simply 
crossing  the  college  yard,  he  returned  to  his  room  so  ex- 
hausted that  he  felt  obliged  to  lie  down  and  rest. 

His  inability  to  keep  up  with  his  duties  caused  him 
greater  and  greater  worry,  and  he  suffered  constantly  from 
his  head  feeling  tired,  which  rendered  it  impossible  for  him 
to  concentrate  his  mind  any  length  of  time.  This  tired 
feeling  in  the  head  soon  gave  way  to  a  constant  sense  of 
pressure  over  the  forehead  and  the  vertex,  which  caused 


IO2  Psychotherapeutics 

him  much  alarm.  Frequently  when  this  was  very  distress- 
ing, he  would  be  seized  with  the  idea  that  he  was  going  to 
lose  his  mind. 

A  careful  examination  of  the  patient  showed  an  almost 
perfect  physical  condition.  Never  have  I  seen  more  splendid 
muscular  development.  There  was  no  evidence  of  any  dis- 
turbance of  the  organs  of  the  thoracic  or  the  abdominal 
cavities.  The  pupils  were  normal  in  size  and  reacted  well. 
The  knee  jerks  were  equal  and  slight.  The  contrast  be- 
tween his  story  of  utter  physical  exhaustion,  and  the  picture 
he  presented  of  such  strength  was  very  striking.  Nor  was 
he  able  to  understand  why  he  could  not  enter  into  things  with 
his  customary  vigor.  After  explaining  in  detail  to  him 
the  nature  of  his  condition  and  the  factors  which  were  help- 
ing to  keep  him  from  recovery,  he  was  made  to  realize  what 
his  possibilities  were,  and  how  he  must  apply  himself  to  gain 
his  ends.  The  tasks  put  upon  him  were  made  rapidly  more 
and  more  difficult,  so  that  at  the  end  of  six  weeks  he  was  doing 
a  normal  amount  of  studying,  and  was  rated  as  one  of  the 
first-class  men  in  putting  the  shot  and  throwing  the  hammer. 

His  condition  continued  to  improve  so  that  the  following 
fall  he  played  on  the  'Varsity  football  team,  and  then  as  well 
as  during  the  two  succeeding  years  of  play  was  considered  a 
tower  of  strength. 

Except  for  a  temporary  difficulty  of  an  entirely  different 
nature  this  patient  has  been  quite  well  since  his  recovery,  a 
period  now  of  several  years. 

CASE  II.  The  second  patient  was  a  strong,  well-looking 
man  of  twenty-two,  who  for  years  had  been  incapacitated 
for  carrying  on  the  work  of  daily  life  on  account  of  his  nervous 
condition. 

A  few  years  ago  he  was  working  very  hard  in  college, 
and  studying  in  a  law  office  in  addition.  This  he  was  able  to 
keep  up  for  a  year,  although  he  grew  progressively  more  tired, 
and  found  himself  more  and  more  limited  in  his  capacity  for 


The  'Treatment  of  Fatigue  States  103 

performing  his  duties.  At  the  end  of  this  time,  one  evening 
when  he  arrived  at  his  home,  as  he  was  going  upstairs  he  was 
suddenly  overpowered  with  a  sensation  as  if  he  were  let  down 
through  a  stairway,  and  were  melting  away  into  nothingness, 
and  was  conscious  of  a  feeling  of  overpowering  fear.  A  cold 
sweat  broke  out  all  over  him,  so  thathegothot  water  bottles  and 
crawled  into  bed  under  heavy  coverings,  still  feeling  strange. 
From  that  night  on,  the  feeling  of  exhaustion  which  had 
been  increasing  for  a  number  of  months  became  doubly 
strong,  and  rendered  him  unable  to  carry  on  his  work  and 
studies.  In  the  mean  time  similar  attacks  of  fear  and  un- 
reality returned  at  various  intervals,  and  he  was  advised  to 
leave  his  home  and  to  enter  a  sanatorium. 

The  following  two  years  were  spent  in  various  sanatoria 
and  retreats,  the  patient  meanwhile  getting  no  stronger,  but 
more  and  more  losing  confidence  in  himself.  Ac  the  time 
when  he  made  his  first  visit  to  me  he  was  unable  to  go  about 
alone  on  account  of  his  great  sense  of  fear  that  something 
would  happen.  The  outside  world  seemed  strange  in  a  way 
which  he  found  it  difficult  to  explain.  There  was  no  power 
to  concentrate  the  attention  in  following  a  conversation  or  in 
attempting  to  read;  to  such  a  degree  did  this  symptom  exist 
that  he  found  it  impossible  to  read  a  single  paragraph  in  the 
newspaper  understandingly.  Attempts  to  move  about  simply 
rendered  him  more  tired,  and  on  the  whole  he  declared  himself 
utterly  discouraged  in  trying  to  make  any  progress  against  his 
illness. 

The  treatment  of  the  condition  was  rendered  difficult  in 
the  beginning  by  the  inability  of  the  patient  to  give  his  at- 
tention long  enough  to  grasp  a  continued  line  of  argument. 
This  was  overcome  gradually  by  forcing  him  to  devote  all 
his  energies  to  mastering  the  content  of  longer  and  longer 
passages  of  reading  at  stated  intervals,  till  he  found  himself 
able  to  read  or  attend  lectures  without  effort.  Meanwhile 
his  fears  were  dispelled  by  the  substitution  of  new  complexes, 


IO4  Psychotherapeutics 

so  that  now  for  a  year  he  has  been  carrying  on  more  work  than 
is  done  by  the  average  law  student,  and  performing  his  duties 
in  an  eminently  satisfactory  manner. 

Whereas  the  first  case  cited  represents  the  psychical 
fatigue  (hyperesthesia)  as  related  more  to  physical  effort,  the 
second  case  is  the  type  in  which  a  physiological  fatigue  state 
developed  into  a  psychopathological  fatigue  and  finally  into 
a  condition  of  psychasthenia.  Such  cases  at  times  have  the 
distressing  attacks  of  unreality  and  the  overpowering  fears 
developed  to  such  a  degree  that  hypnosis  is  necessary  to 
overcome  them.  That  new  complexes  may  be  forced  upon 
them  in  the  waking  state  when  the  distressing  symptoms  are 
not  too  deeply  grounded  is  evidenced  by  the  frequency  with 
which  this  end  has  been  accomplished. 


PSYCHO-ANALYSIS  IN  PSYCHOTHERAPY 

ERNEST  JONES,  M.D.,  M.R.C.P.  (LOND.) 

Demonstrator  of  Psychiatry,  University  of  Toronto.    Patholo- 
gist to  the  Toronto  Hospital  for  the  Insane 


PSYCHO-ANALYSIS  IN  PSYCHOTHERAPY 

THE  evolution  of  psychotherapy,  like  that  of  all 
other  modes  of  treatment,  is  marked  by  an  ever- 
increasing  precision  in  method  and  an  ever-deepen- 
ing comprehension  of  the  conditions  to  which  it  is 
applicable.  Progress  in  these  two  respects  must  always  go 
hand  in  hand,  for  the  moment  therapeutics  becomes  divorced 
from  pathology  and  diagnosis  it  leaves  its  scientific  basis  and 
stands  in  danger  of  approximating  to  that  medical  charla- 
tanery  which  it  is  the  highest  interest  of  our  profession  to 
resist.  The  two  studies  are  peculiarly  interwoven  in  the 
case  of  the  psycho-analytic  form  of  psychotherapy,  for, 
as  I  shall  presently  indicate,  treatment  is  here  carried  out  by 
simultaneously  laying  bare  and  remedying  the  pathological 
mechanisms  at  the  basis  of  the  malady.  From  this  point  of 
view  we  can  discern  two  stages  in  the  development  of  any  new 
method  of  treatment,  and  these  I  can  best  illustrate  by  a 
reference  to  more  familiar  methods,  for  instance  the  opera- 
tions of  trephining  or  of  laparotomy.  When  the  possibility 
of  these  operations  was  first  realized  we  saw  the  first  stage 
in  development,  in  which,  namely,  they  were  regarded  merely 
as  an  adjunct  to  the  therapeutic  armamentarium,  and  were 
applied  in  the  relief  of  conditions  that  were  already  well 
known  and  studied  on  established  pathological  lines.  The 
second  stage  arose  when,  through  the  repeated  performance 
of  such  operations,  conditions  that  could  be  relieved  by  them 
came  to  be  studied  anew,  fresh  aspects  of  pathology  opened 
up,  and  questions  of  precise  diagnosis  that  had  previously 
been  academic  problems  of  trivial  interest  now  became 
urgent  matters  of  life  and  death.  A  moment's  reflection 
on  the  history  of  appendicitis  will  remind  you  of  how  little 
we  knew  of  the  pathology,  the  diagnosis,  or  even  the  existence 
of  the  affection  until  the  surgeon's  knife  showed  that  it  could 
be  cured.  We  might,  in  fact,  paraphrase  the  motto  under- 

107 


io8  Psychotherapeutics 

lying  British  Imperialistic  policy,  to  wit,  that  trade  follows 
the  flag,  and  say  that  in  medicine  diagnosis  follows  treatment. 
Now  in  psychotherapy  most  of  the  medical  world  is  at 
present  only  entering  on  the  first  stage.  That  the  medical 
world  of  America  will  definitely  enter  on  this  stage  as  a 
prelude  to  further  advancement  will,  I  trust,  be  one  of  the 
results  of  this  afternoon's  conference.  In  this  stage  we 
clearly  recognize  that  we  have  secured  a  new  therapeutic 
weapon  of  the  utmost  value,  which  we  may  describe  as  the 
capacity  to  alleviate  certain  complaints  by  purely  mental 
measures,  in  other  words  as  psychotherapy  in  its  broadest 
sense.  Our  attitude  towards  the  nature  of  these  complaints, 
however,  remains  in  this  stage  substantially  the  same  as  it 
was  when  they  were  treated  only  by  physical  remedies. 
Hence  we  may  see  the  strange  picture  of  a  physician  remov- 
ing by  verbal  suggestion  a  symptom  which  he  considers  is 
produced  by  a  toxin  circulating  in  the  blood.  However,  a 
thoughtful  person  who  employs  any  form  of  psychotherapy 
soon  realizes  that  a  symptom  which  can  be  removed  by 
mental  measures  is  in  all  probability  of  a  mental  nature.  It 
may  parenthetically  be  remarked  that  he  further  realizes  how 
the  suffering  endured  by  the  patient,  so  far  from  being  unreal, 
is  all  the  more  dreadful  and  formidable  for  having  a  mental 
and  not  a  physical  origin.  A  non-appreciation  of  this  im- 
portant fact  is  still  all  too  common.  Only  recently  an  article 
appeared  in  one  of  the  leading  medical  journals  in  which 
the  writer  remarked :  "  In  this  manner  I  hope  that  we  will 
always  be  able  to  trick  a  malingerer  or  hysterical  subject  into 
betraying  the  falsity  of  his  claim."  This  attitude,  though 
rarely  in  such  an  outspoken  form,  is  frequently  implicit  in 
medical  writings,  and  cannot  be  too  strongly  condemned. 
Apart  from  yielding  an  inkling  of  the  mental  nature  of  various 
disorders,  the  first  stage  in  the  evolution  of  psychotherapy 
is  characterized  by  an  indeterminate  attitude  towards  the 
origin  and  pathogenesis  of  them.  The  older  conceptions 


Psycho-analysis  in  Psychotherapy  109 

have  begun  to  dissolve,  but  the  knowledge  won  by  the  new 
method  of  treatment  has  not  yet  been  formulated.  Psycho- 
therapy is  in  this  stage  employed  in  a  quite  empiric  way,  and 
the  physician  either  does  not  concern  himself  with  the 
intrinsic  modus  operandi  of  his  treatment,  or  else  offers  expla- 
nations of  it  which  are  so  superficial  as  to  be  of  little  scientific 
value. 

Psycho-analysis  represents  the  second  stage  in  the 
evolution  of  psychotherapy.  Here  a  deeper  insight  is  sought 
into  the  essential  nature  and  origin  of  the  morbid  phenomena 
with  a  view  to  obtaining  a  fuller  understanding  of  the  aims 
of  treatment  and  so  to  achieving  a  greater  precision  in  the 
application  of  it.  The  psycho-analytic  method  we  owe 
almost  completely  to  the  genius  of  Professor  Freud  of  Vienna, 
who  in  the  past  sixteen  years  has  wrought  it  into  an  elaborate 
science  of  which  I  can  here  give  only  the  most  summary 
outline.  The  method  is  based  on  the  knowledge  that  the 
symptoms  present  in  the  psycho-neuroses  owe  their  origin 
to  a  conflict  between  two  groups  of  ideas  or  mental  processes 
which  cannot  be  brought  into  harmony  with  each  other. 
One  complex  of  mental  processes  is  for  some  reason  or  other 
of  such  a  kind  as  to  be  inacceptable  to  the  main  body  of  the 
personality.  The  personality  fails  to  assimilate  it,  will  have 
nothing  to  do  with  it,  tries  to  forget  it,  to  submerge  it,  to 
repress  it.  The  repressed  complex  then  takes  on  an  auto- 
matic existence,  and  acts  as  an  irritating  foreign  body  in  the 
same  way  as  any  physical  foreign  body  that  has  not  been 
absorbed.  From  this  point  of  view  we  may  define  the  pa- 
thology of  the  psycho-neuroses  as  a  defect  in  assimilation. 

Let  me  illustrate  my  meaning  with  a  concrete  instance. 
A  man  conceives  an  attraction  toward  the  wife  of  a  near 
friend  or  relative,  and  in  his  imagination  perhaps  plays  with 
the  thought  of  what  might  happen  were  the  friend  to  meet 
with  a  fatal  accident.  If  he  honestly  faces  his  wish  and 
realizes  its  nature  he  will  instantly  see  that,  though  possibly 


IIO  Psychotherapeutics 

a  perfectly  natural  one,  it  is  of  such  a  kind  that  for  social  and 
ethical  reasons  it  must  obviously  be  suppressed.  If  he  adopts 
this  healthy  attitude  he  will  probably  think  no  more  about 
the  matter  except  in  the  most  harmless  way.  1  he  wish- 
complex  is  here  assimilated  by  the  main  body  of  the  person- 
ality. If  on  the  other  hand  he  regards  the  mere  possibility 
of  entertaining  such  a  wish  as  a  sin  and  a  sign  of  the  most 
desperate  iniquity  he  may  refuse  to  own  up  to  himself  that 
he  has  ever  felt  it,  even  momentarily;  whenever  the  thought 
occurs  to  him  he  endeavors  to  put  it  from  him,  to  get  away 
from  it,  in  other  words  to  repress  ('  verdrangen ')  it.  The 
complex  here  is  not  assimilated,  it  therefore  continues  to  act, 
and  the  more  the  man  strives  to  escape  from  it,  the  more 
hauntingly  does  it  torment  him.  He  has  now  become  the 
prey  to  a  fixed  idea  which  is  out  of  his  control,  and  which 
evinces  its  independence  by  appearing  irregularly  whether 
he  wills  it  or  not.  In  actual  practice  we  never  meet  with 
cases  so  simple  as  this,  but  the  instance  will  serve  to  illus- 
trate the  notion  I  am  trying  to  convey,  namely  that  certain 
mental  processes,  particularly  strivings,  desires,  and  impulses, 
if  they  are  not  absorbed  in  the  main  stream  of  the  personality 
are  apt  to  manifest  an  independent  activity  out  of  control 
of  the  will.  This  activity  is  usually  of  a  low  order,  of  an 
automatic  and  almost  reflex  kind,  and  —  if  I  may  be  allowed 
to  use  the  term  in  a  clinical  and  non-philosophic  sense  —  it  is 
generally  an  unconscious  activity,  that  is  to  say  it  operates 
without  the  subject's  being  aware  of  it. 

As  I  have  just  said,  matters  are  not  so  simple  in  practice, 
and  what  actually  happens  is  that  the  activity  of  the  repressed 
complex  is  manifested  not  directly  but  indirectly  in  some 
distorted  form  that  is  often  hard  to  recognize.  In  the  above 
example,  for  instance,  the  subject  might  have  counter- 
balanced his  real  attitude  towards  his  friend  by  developing 
an  exaggerated  solicitude  for  his  welfare,  and  have  shown 
great  concern  and  dread  whenever  the  friend  ran  the  slightest 


Psycho-analysis  in  Psychotherapy  III 

risk  of  accident  or  danger.  Again,  an  abnormally  strong 
emotion  might  be  evoked  by  anything  accidentally  associated 
with  the  persons  in  question,  a  condition  that  Professor 
Morton  Prince  described  some  ten  years  ago  under  the  name 
of  "  association  neurosis."  This  distortion  in  the  manifesta- 
tion of  the  activity  of  the  mental  complex  is  often  exceedingly 
involved,  and  one  of  the  main  difficulties  in  the  psycho- 
analytic method  is  the  unravelling  of  the  confused  end- 
product,  which  clinically  we  call  a  symptom.  The  psycho- 
logical mechanisms  by  means  of  which  the  distortion  is 
brought  about  are  very  intricate,  so  that  in  the  time  allotted 
it  would  be  impossible  for  me  to  describe  them.  They  have 
been  worked  out  with  great  accuracy  and  detail  by  Freud 
and  Jung,  and  an  exact  study  of  them  is  essential  to  the  use 
of  the  psycho-analytic  method. 

Investigation  on  the  lines  presently  to  be  indicated  dis- 
closes the  fact  that  every  psycho-neurotic  symptom  is  to  be 
regarded  as  the  symbolic  expression  of  a  submerged  mental 
complex  of  the  nature  of  a  wish.  The  wish  itself  on  account 
of  its  inacceptable  nature  is  concealed,  and  the  symptom 
arises  as  a  compromise  between  it  and  the  repressing  force 
exerted  by  the  main  personality.  The  stream  of  feeling  that 
characterizes  the  wish  is  dammed  up,  it  can  find  no  direct 
outlet,  and  so  flows  into  some  abnormal  direction.  The 
metaphor  of  "  side-tracking  "  is,  I  believe,  used  in  American 
psychiatric  circles  to  indicate  this  process.  In  more  technical 
phraseology  we  may  say  that  the  affect  of  the  original  com- 
plex is  inhibited,  and  so  becomes  transposed  on  to  an  in- 
different mental  process.  This  indifferent  mental  process 
has  now  become  invested  with  the  strength  of  feeling  that 
properly  belongs  to  the  original  complex,  and  so  may  be  said 
to  replace  the  complex.  Thus  arises  what  Professor  Adolf 
Meyer  calls  a  substitution  neurosis,  in  which  an  abnormal 
outlet  has  been  found  for  a  pent-up  affective  process.  The 
outlet  may  be  in  a  purely  mental  direction,  in  which  case  we 


112  Psychotherapeutics 

have  such  a  symptom  as  a  phobia,  or  towards  various  bodily 
processes,  a  condition  that  Freud  calls  conversion-hysteria, 
in  which  case  we  have  such  symptoms  as  a  tremor  or  a  paraly- 
sis. In  the  symptom  the  patient  obtains  a  certain  uncon- 
scious gratification  of  the  repressed  wish,  and  this  means  of 
obtaining  the  gratification,  however  perverse  and  abnormal 
it  may  be,  is  still  the  only  means  possible  to  the  patient  under 
the  circumstances.  This  fact  explains  the  obstinacy  with 
which  such  a  patient  may  instinctively  cling  to  his  symptoms, 
and  is  one  of  the  causes  of  the  resistance  that  the  physician 
encounters  when  trying  to  remove  these.  I  need  hardly 
remind  you  that  this  obstinacy  is  often  erroneously  inter- 
preted even  by  physicians  as  indicating  mere  wilful  perversity, 
a  mistake  that  does  not  conduce  to  success  in  treatment. 
Not  only  does  the  observer  commonly  fail  to  understand  the 
significance  of  the  symptom,  but  the  patient  himself  has  no 
knowledge  of  its  meaning  or  origin.  In  fact,  enabling  the 
patient  to  discover  and  appreciate  the  significance  of  the  mental 
process  that  manifests  itself  as  a  symptom  is  the  central  aim  of 
the  psycho-analytic  method. 

In  carrying  out  this  method  several  procedures  may  be 
adopted  according  to  circumstances.  The  hypnotic  state, 
for  instance,  may  be  utilized  in  the  search  for  forgotten 
memories.  Only  a  very  few  of  those  acquainted  with  the 
psycho-analytic  method  employ  this  procedure  at  all  ex- 
tensively, for  it  has  grave  disadvantages  which  I  need  not 
here  discuss.  Personally  I  employ  it  only  as  a  rare  exception 
and  for  special  reasons;  under  certain  circumstances,  how- 
ever, it  undoubtedly  has  a  legitimate  place.  The  procedure 
introduced  and  developed  by  Freud  is  the  one  most  generally 
used,  and  gives  by  far  the  most  satisfactory  results.  It  is  one 
of  the  ways  of  obtaining  what  is  known  in  psychology  as 
"  free  association,"  and  is  carried  out  by  getting  the  patient 
to  concentrate  his  mind  on  a  given  idea,  generally  one  in 
relation  to  a  symptom,  and  asking  him  to  relate  in  the  order 


Psycho-analysis  in  Psychotherapy  113 

of  their  appearance  the  various  thoughts  that  come  to  his 
mind.  It  is  essential  for  him  to  do  this  quite  honestly,  and 
fortunately  we  have  several  objective  tests  of  his  behavior  in 
this  respect.  He  must  suspend  his  natural  tendency  to 
criticize  and  direct  the  thoughts  flowing  in,  and  must  there- 
fore play  a  purely  passive  part  during  this  stage.  At  first 
he  will  omit  to  mention  a  number  of  thoughts  on  the  ground 
that  they  are  apparently  irrelevant,  unimportant,  or  non- 
sensical, and  others  because  they  are  of  a  painful  or  unpleas- 
ant nature.  After  a  time,  however,  the  length  of  which 
largely  depends  on  his  intelligence  and  sincerity,  he  acquires 
the  capacity  of  adopting  the  non-critical  and  passive  attitude 
essential  to  success. 

Other  means  of  reaching  buried  mental  complexes 
may  briefly  be  mentioned.  A  study  of  various  mannerisms, 
symptomatic  movements  and  tricks  of  behavior,  and  slips 
of  the  tongue  or  pen,  often  reveals  the  automatic  functioning 
of  some  repressed  train  of  thought.  The  word-reaction 
association  method  as  developed  by  Jung  is  of  the  highest 
assistance,  particularly  in  furnishing  us  with  a  series  of  clues 
to  serve  as  starting  points  for  future  analyses.  In  this  method 
a  series  of  test-words  are  called  out  to  the  patient,  who  has 
to  respond  with  the  first  word  or  thought  thus  called  to  his 
mind.  From  a  general  review  of  the  kind  of  responses 
given  much  can  be  learned  about  the  mentality  of  the  patient 
and  the  type  of  psychosis  present.  Further,  by  noting 
certain  peculiarities  in  the  individual  reactions  we  may 
discover  certain  complexes  or  trains  of  thought  which  possess 
for  the  patient  a  high  emotional  value,  and  these  can  then 
be  followed  and  studied  more  fully.  The  peculiarities  I 
refer  to  are  ten  or  twelve  in  number.  The  chief  are:  undue 
delay  in  the  time  of  reaction,  failure  to  respond  at  all,  re- 
sponse by  repetition  of  the  test-word,  perseveration  affecting 
the  succeeding  reactions,  anomalous  clang  associations, 
assimilation  of  the  test-word  in  an  unusual  sense,  and 


1 14  Psychotherapeutlcs 

erroneous  reproduction  of  the  reaction  when  the  memory 
for  it  is  subsequently  tested.  Last  but  not  least  is  the 
analysis  of  the  patient's  dreams  by  means  of  the  special 
technique  introduced  by  Freud.  The  study  of  dreams  is  in 
this  connection  of  supreme  importance,  for  of  all  the  means 
at  our  disposal  it  is  the  one  that  best  enables  us  to  penetrate 
into  and  understand  the  most  hidden  parts  of  the  mind.  No 
one  can  have  more  than  an  outsider's  notion  of  the  psycho- 
analytic method  who  has  not  thoroughly  studied  Freud's 
Traumdeutung,  for  in  this  work  he  has  laid  down  the  tech- 
nique of  his  methods,  and  discussed  the  principles  on  which 
they  are  based,  with  a  fulness  to  be  found  nowhere  else  in 
his  writings. 

By  means  of  the  methods  just  outlined  we  are  enabled 
to  determine  the  origin  of  the  symptom  by  retracing  the  steps 
along  which  its  pathogenesis  proceeded.  It  is  impossible  to 
deal  with  the  underlying  complexes,  to  discharge  their  pent-up 
affect,  to  render  them  more  assimilable  by  the  patient,  unless 
one  succeeds  in  this  task  and  brings  them  to  the  full  light  of 
day.  The  symptoms  constitute  a  veiled  language  in  which 
hidden  thoughts  and  desires  find  the  only  means  allowed 
them  of  coming  to  expression.  We  have  to  get  the  patient  to 
translate  his  symptoms  into  more  direct  language,  and  thus 
to  understand  and  appreciate  the  origin  of  them.  In  so 
doing  we  give  the  patient  a  deeper  insight  into  the  workings 
of  his  mind,  so  that  he  is  enabled  to  correct  abnormal  devia- 
tions, to  overcome  internal  inhibitions  and  impediments, 
and  to  acquire  a  more  objective  standpoint  towards  the  re- 
pressed mental  complexes,  the  automatic  functioning  of 
which  has  produced  the  morbid  manifestations.  He  is  in 
this  way  able  to  free  his  personality  from  the  constraining 
force  of  these  complexes,  and,  by  taking  up  an  independent 
attitude  towards  them,  to  gain  a  degree  of  self-control  over 
ahis  berrant  thoughts  and  wishes  that  was  previously  im- 
possible. The  method  is  thus  in  almost  every  respect  the 


Psycho-analysis  in  Psychotherapy  115 

reverse  of  treatment  by  suggestion,  although  several  would-be 
critics  have  naively  exposed  their  ignorance  of  the  subject 
in  maintaining  that  the  successful  results  are  produced  by 
suggestion.  In  suggestion  treatment  the  physician  adds 
something  to  the  patient's  mind, —  confidence,  belief,  etc., — 
and  thus  makes  the  patient  more  dependent  on  him.  The 
psycho-analytic  method  does  not  add;  it  takes  away  some- 
thing, namely  inhibition.  It  enables  the  patient  to  disen- 
tangle confused  mental  processes,  and,  by  giving  him  control 
over  the  disharmonies  of  his  mind,  leads  him  to  develop 
a  greater  measure  of  self-reliance  and  independence.  The 
training  received  by  the  patient  is  thus  an  educative  one  in 
the  highest  sense  of  the  word,  for  he  not  only  achieves  a  richer 
development  of  will  power  and  self-mastery,  but  acquires 
an  understanding  of  his  own  mind  which  is  of  incalculable 
value  for  future  prophylaxis.  He  grows  both  in  capacity 
to  know  and  in  ability  to  do. 

The  conditions  that  lend  themselves  to  psycho-analytic 
treatment  comprise  practically  all  forms  of  psycho-neurosis, 
the  different  types  of  hysteria,  the  phobias,  obsessions, 
anxiety  neuroses,  and  even  certain  kinds  of  sexual  perver- 
sions. I  shall  refrain  from  relating  any  individual  cases,  for 
to  do  so  would  be  only  to  weary  you  with  the  recital  of  a  list 
of  typical  and  atypical  instances  of  these  various  conditions. 
It  is  further  impossible  for  me  to  narrate  any  single  instance 
of  an  analysis,  for  in  every  case  the  richness  of  material  is  so 
great  that  it  would  take  several  hours  to  give  even  an  outline 
of  the  main  points  in  the  case. 

The  results  obtained  by  the  treatment,  though  by  no 
means  ideal,  are  yet  very  gratifying.  They  surpass  those 
obtained  by  simpler  methods  in  two  chief  respects,  namely 
in  permanence  and  in  the  prophylactic  value  they  have  for 
the  future.  Although  most  symptoms  can  be  removed  by 
other  methods,  such  as  hypnotism,  yet  any  one  who  has  de- 
voted much  time  to  the  study  of  these  cases  knows  how  great 


Il6  Psychotherapeutics 

is'the  tendency  to  relapse,  to  recurrence,  and  to  the  appear- 
ance of  fresh  groups  of  symptoms.  Mild  cases  can  indeed 
be  not  only  alleviated  but  even  cured  by  the  simpler  psycho- 
therapeutic  measures,  so  that  these  all  have  their  sphere  of 
usefulness;  severe  cases,  on  the  other  hand,  need  a  more 
radical  treatment,  an  uprooting  of  the  actual  morbid  agents. 
It  is  easy  to  understand  how  this  must  be  so.  Hypnotic  and 
other  suggestion  acts  merely  by  blocking  the  outward  mani- 
festation of  the  underlying  pathogenetic  idea.  The  idea 
itself  persists,  because  it  has  not  been  reached  and  dealt  with, 
and  sooner  or  later  it  will  again  manifest  itself  either  in  the 
same  direction  or  in  some  fresh  one.  The  analogy  of  a 
tubercular,  or  better  still  of  an  actinomycotic  abscess  occurs 
to  me  in  this  connection.  If  the  suppurating  sinus  is  forcibly 
plugged  then  the  symptom  of  discharging  pus  is  removed, 
but  sooner  or  later  the  pent-up  pus  will  find  a  vent  in  either 
the  same  or  a  fresh  direction.  Before  satisfactory  healing 
can  take  place  the  tension  must  be  relieved  by  instituting 
free  drainage  for  each  pus  pocket,  and  the  more  thoroughly 
the  focus  of  the  disease  is  dealt  with  the  better  will  be  the 
result. 

A  few  words  are  now  necessary  on  the  clinical 
applicabilities  and  limitations  of  the  method.  It  is  a  method 
that  makes  great  demands  on  both  physician  and  patient. 
Apart  from  technical  knowledge  the  physician  must  evi- 
dently possess,  not  only  unimpeachable  integrity,  but  also 
a  considerable  measure  of  tact,  patience,  and  sympathetic 
understanding;  without  these  qualifications  he  is  unlikely 
to  gain  the  patient's  confidence  to  the  requisite  degree.  The 
treatment  further  makes  a  great  call  on  his  time.  Freud 
often  finds  it  necessary  to  devote  to  a  patient  an  hour  a  day 
for  three  years,  but  he  acknowledges  that  the  cases  sent  to 
him  are  generally  of  a  very  severe  nature.  In  milder  cases 
one  can  achieve  very  satisfactory  results  in  a  few  months, 
a  fact  to  which  I  can  fully  attest  from  my  own  experience. 


Psycho-analysis  in  Psychotherapy  117 

The  amount  of  time  may  appear  excessive  unless  one  re- 
members the  hugeness  of  the  task  imposed,  for  in  all  cases 
the  roots  of  the  trouble  go  back  to  early  childhood,  and  im- 
portant modes  of  reactions  have  to  be  altered  which  have 
been  fixed  and  stereotyped  for  many  years.  When  we  con- 
sider how  much  trouble  and  time  frequently  has  to  be 
expended  in  the  orthopedic  straightening  of  a  deformed  limb, 
we  should  not  grudge  the  same  to  the  far  more  intricate  task 
of  the  orthopsychic  training  of  a  deformed  mind,  especially 
when  this  results  in  converting  an  intolerable  existence  into 
a  happy  life,  and  a  person  paralyzed  by  doubts,  fears,  and 
suffering  into  an  active  and  useful  citizen. 

The  demands  made  on  the  patient  are  no  less  great. 
The  results  of  the  treatment  will  vary  with  the  intelligence, 
courage,  honesty,  and  perseverance  he  shows.  With  stupid 
and  quite  uneducated  patients  relatively  little  can  be  done, 
so  that  happily  we  can  most  help  those  whose  value  to  the 
world  is  greatest.  Again,  age  sets  a  formidable  barrier  to 
our  efforts.  In  old  age,  when  the  plasticity  of  the  mind  is 
diminished,  far  less  can  be  done  than  at  an  earlier  period, 
and  furthermore  the  time  necessary  to  trace  back  the  errone- 
ous mental  reactions  through  so  many  years  is  naturally 
longer.  Still  I  have  had  a  few  fairly  satisfactory  results  even 
above  the  age  of  fifty. 

It  will  be  realized  that  the  method  is  at  present  not  one 
generally  applicable  by  the  practising  physician.  Not  only 
is  the  time  necessary  for  the  treatment  a  great  hindrance, 
but  also  a  laborious  special  training  is  necessary  before  the 
technique  of  psycho-analysis  can  be  acquired  to  an  adequate 
extent.  It  is  generally  admitted  that  this  demands  three 
years'  incessant  practice,  a  good  previous  knowledge  of 
neurology  being  assumed.  Here,  as  elsewhere,  therefore, 
good  work  exacts  arduous  labor,  and  there  is  no  royal  road 
to  the  art  of  handling  the  most  intricate  and  delicate  machine 
we  know  of,  the  human  mind. 


Ii8  Psychotherapeutics 

You  may  now  legitimately  ask  why  I  have  taken  up  so 
much  of  your  time  in  describing  a  mode  of  treatment  which 
I  acknowledge  not  many  will  have  the  opportunity  to  learn 
or  to  apply.  My  answer  is  a  twofold  one.  In  the  first  place 
I  am  not  one  of  those  who  hold  that  the  general  physician 
should  be  cut  off  from  all  advancing  knowledge  except  that 
which  he  can  immediately  apply  in  his  daily  work.  No 
physician  can  apply  all  methods  of  diagnosis  and  treatment, 
but  it  is  surely  well  that  he  should  at  least  be  aware  of  the 
existence  of  them.  I  cannot  believe  that  because  a  country 
practitioner  is  not  expected  to  apply  the  Wassermann  test 
in  the  diagnosis  of  syphilis,  or  to  perform  excision  of  the 
Gasserian  ganglion  for  the  relief  of  trigeminal  neuralgia,  it 
is  therefore  better  for  him  not  to  know  about  such  methods. 
In  the  second  place  I  wish  to  contribute  to  the  general  effect 
that  this  symposium  must  have  in  bringing  home  to  you  in 
some  degree  the  present  unsatisfactory  state  of  medical 
education  so  far  as  psychology  is  concerned,  for  this  is  the 
main  cause  of  the  helplessness  of  the  medical  profession 
against  the  very  maladies  that  are  the  triumph  of  the  quack, 
religious  or  otherwise.  The  sooner  we  honestly  face  the 
shameful  but  undeniable  fact  that  unqualified  empirics  can 
relieve  distressing  affections  in  cases  that  have  defied  medical 
skill,  can  produce  results  where  we  fail,  the  sooner  will  this 
flagrant  lack  in  our  system  of  education  be  remedied,  and 
the  better  will  it  be  for  the  dignity  and  honour  of  the  medical 
profession.  While  the  present  state  of  affairs  lasts,  in  which 
most  physicians  are  given  not  five  minutes'  training  in  psy- 
chology in  the  five  years  of  their  student  life,  and  in  which 
there  is  no  teacher  of  clinical  psychology  in  any  university 
or  medical  school  in  the  country,  our  profession  must  submit 
to  being  the  prey  of  the  charlatan  and  the  mock  of  the  scoffer. 


THE  PSYCHOTHERAPEUTIC  VALUE  OF  THE 
HYPNOIDAL  STATE 

BY  BORIS  SIDIS,  M.A.,  PH.D.,  M.D. 

Brookline,  Mass. 


THE  PSYCHOTHERAPEUTIC  VALUE  OF  THE 
HYPNOIDAL  STATE 

HYPNOSIS  has  long  ago  been  brought  before  the 
scientific  world  as  a  state  in  which  maladies  of 
a  functional  or  of  a  psychic  origin,  such  as  the 
various  forms  of  hysterias,  obsessions,  and 
phobias,  can  be  alleviated  and  even  permanently  cured. 
Dr.  Frederic  H.  Gerrish,  your  president,  has  in  his  address 
opened  this  subject  before  this  society.  The  works  of 
Braid,  Charcot,  Liebault,  Bernheim,  Forel,  Vogt,  Breuer 
and  Freud,  Schrenck-Notzing,  Prince,  Bechterew,  Janet, 
Babinski,  and  others,  are  well  known  to  the  student  in  ab- 
normal psychology.  Recently,  however,  many  medical 
men  of  reputation,  such  as  Dubois,  Freud,  Prince,  Putnam, 
Taylor,  Waterman,  Donley,  and  many  others,  could  not 
help  being  impressed  by  the  practical  limitations  of  the 
hypnotic  state.  Many  patients  refuse  to  submit  to 
treatment,  being  afraid  of  occult  influences.  Then  again 
a  great  number  of  patients  are  difficult  to  hypnotize.  There 
is  no  denying  the  fact  that  there  exists  a  strong  feeling  of 
distrust  among  many  conservative  men  who  are  not 
acquainted  with  the  amount  of  scientific  work  that  has  been 
lately  done  in  the  domain  of  abnormal  psychology.  This 
strong  feeling  against  the  use  of  the  hypnotic  state  as  a 
therapeutic  agent  in  psychopathic  diseases  is  unfortunately 
often  found  among  many  representative  men  of  the  American 
medical  profession. 

An  American  editor  of  a  well-known  American  medical 
journal  unhesitatingly  rejects  work  on  psychopathology 
and  psychotherapy.  The  editor  is  apparently  under  the 
impression  that  he  is  keeping  up  the  high  standard  of 
American  medical  science, —  that  papers,  disquisitions,  and 
discussions  on  diarrhea,  constipation,  enemas,  eczema, 
hemorrhoids,  and  cognate  scientific  investigations  are  essen- 

121 


122  Psychotherapeutics 

tially  valuable,  dignified,  and  suitable  to  the  mind  and  needs  of 
the  medical  reader.  In  Germany,  France,  Italy,  Austria, 
Russia,  work  in  abnormal  psychology  has  long  ago  gained 
recognition  as  a  science  of  theoretical  and  practical  impor- 
tance to  the  physician  and  even  to  the  lawyer,  while 
in  the  United  States  conservatism  in  regard  to  abnormal 
psychology  is  still  paraded  as  a  badge  of  orthodox  medical 
respectability.  The  opposition  to  psychopathology  is  mani- 
fest, when  it  comes  to  the  use  of  the  hypnotic  state. 

Since  hypnosis  meets  with  so  much  opposition  the  ques- 
tion naturally  arises, —  Is  it  possible  to  affect  and  modify 
pathological  mental  states  outside  hypnosis  ?  The  problem 
is  practical  and  requires  a  solution.  In  "  The  Psychology  of 
Suggestion  "  I  pointed  out  on  the  strength  of  a  number  of 
experiments  that  suggestibility  can  also  be  induced  in  the 
normal  waking  state.  I  have  also  shown  that  among  the 
conditions  of  normal  and  abnormal  suggestibility  monotony 
and  limitation  of  activity  play  an  important  role.  Any 
arrangement  tending  to  produce  monotony  and  limitation 
of  voluntary  activity  brings  about  a  state  of  suggestibility 
termed  by  me  subwaking  or  hypnoidal,  a  state  in  which 
mental  life  can  be  affected  with  ease.  The  induction  of  the 
state  is  termed  hypnoidization. 

In  the  hypnoidal  state  consciousness  becomes  somewhat 
vaguer  than  in  the  waking  condition ;  memory  is  more  diffused, 
so  that  experiences  apparently  long  forgotten  come  in  bits 
and  scraps  to  the  foreground  of  consciousness.  Emotional 
excitement  subsides,  voluntary  activity  is  changed  to  passivity, 
and  suggestions  meet  with  little  resistance.  The  subwaking 
state  is  above  all  a  rest-state,  a  state  of  physical  and  mental 
relaxation. 

The  favorable  therapeutic  results  obtained  by  me  led 
to  a  closer  study  of  what  I,  some  thirteen  years  ago, 
regarded  as  a  peculiar  mental  condition.  The  subwaking 
or  hypnoidal  state  is  essentially  an  intermediate  state  belong- 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State   123 

ing  to  the  borderland  of  mental  life.  On  the  one  hand  the 
hypnoidal  state  closely  touches  on  the  waking  state,  on  the 
other  it  merges  into  hypnosis  and  sleep.  A  close  study  of 
the  subwaking  state  shows  that  it  differs  from  the  hypnotic 
state  proper  and  that  it  cannot  be  identified  with  light  hyp- 
nosis. In  my  years  of  study  of  patients  and  subjects  I  have 
observed  the  presence  of  the  subwaking  state  before  the 
development  of  hypnosis  and  also  before  the  oncome  of  sleep. 
When  again  sleep  and  hypnosis  pass  into  waking,  the  hyp- 
noidal state  reappears.  The  hypnoidal  state  may  therefore 
be  regarded  as  a  transitional,  intermediate  state. 

The  subwaking  state  may  be  said  to  partake  not  only 
of  the  nature  of  waking  and  sleep,  but  also  to  possess  some 
characteristics  of  hypnosis,  namely  suggestibility.  It  is 
clear  that  from  the  character  of  its  mixed  symptomatology 
the  hypnoidal  state  is  variable  and  unstable.  The  subwaking 
state  should,  in  fact,  be  regarded  as  an  equivalent  of  sleep. 
Like  sleep  the  hypnoidal  state  has  many  levels  of  depth.  It 
differs,  however,  from  sleep  by  the  rapidity  of  its  oscillations 
from  level  to  level.  In  the  experiments  of  various  investiga- 
tors sleep  is  found  to  be  represented  by  a  rapidly  rising 
curve  during  the  first  couple  of  hours,  and  by  a  gradually 
descending  curve  during  the  rest  of  the  hours  of  sleep.  No 
such  regularity  of  curve  can  be  observed  in  the  subwaking 
state.  The  depth  of  the  hypnoidal  state  changes  very  rapidly 
and  with  it  the  passive  condition  and  suggestibility  of  the 
patient. 

Thus  far  the  work  was  confined  to  observations  and 
experimentation  on  human  subjects  and  patients,  both  from 
a  theoretical  and  practical  therapeutic  standpoint.  Re- 
cently, however,  I  undertook  at  the  physiological  laboratory 
of  Harvard  Medical  School,  and  also  in  my  own  psycho- 
pathological  laboratory,  a  series  of  experiments  on  the 
manifestations  of  sleep  in  the  ascending  scale  of  animal  life, — 
from  the  frog  and  guinea  pig,  the  cat,  the  dog,  to  the  infant  and 


124  Psychotherapeutics 

adult.*  The  experiments  prove  that  the  hypnoidal  state  is 
by  no  means  confined  to  man,  but  is  also  present  in  the  lower 
stages  of  animal  life.  Furthermore,  the  experiments  clearly 
show  that  the  further  down  we  descend  in  the  scale  of  animal 
life,  the  more  prominent,  the  more  essential  does  the  sub-, 
waking  state  become.  From  the  facts  one  is  forced  to  come 
to  the  conclusion  that  the  hypnoidal  state  is  the  primitive 
rest-state  out  of  which  sleep  has  arisen  in  the  later  stages  of 
evolution.  Sleep  and  hypnosis  have  taken  their  origin  in  the 
hypnoidal  state;  both  hypnosis  and  sleep  are  highly  differ- 
entiated states  and  have  become  evolved  out  of  the  primitive, 
undifferentiated,  subwaking  state,  which  is  the  rest-state,  still 
characteristic  of  the  lowly  organized  forms  of  animal  life. 
In  short,  we  may  say  that  the  hypnoidal  state  is  the  primordial 
sleep-state.  In  man  the  subwaking  state  is  but  in  a  rudi- 
mentary condition, —  it  has  shrunk  to  an  abortive,  transitory, 
momentary  stage  in  the  alternation  of  waking  and  sleep. 

While  in  the  hypnoidal  state  the  patient's  consciousness 
keeps  on  fluctuating  from  moment  to  moment,  now  falling 
deeply  into  a  subconscious  state  in  which  outlived  experi- 
ences are  easily  aroused,  and  now  again  rising  to  the  level 
of  waking  consciousness.  The  experiences  come  often  in 
fragments  which  gradually  coalesce  and  form  a  connected 
series  of  interrelated  systems,  apparently  long  gone  and 
forgotten.  The  recognition  is  fresh,  vivid,  instinct  with  life, 
as  if  the  experiences  had  occurred  the  day  before.  The 
revived  experiences  are  in  many  cases  confirmed  by  some 
relative  or  intimate  friend.  This  characteristic  of  getting 
access  to  subconscious  experiences  lost  to  the  patient's 
personal  consciousness  is  what  makes  the  hypnoidal  state 
such  a  valuable  instrument  in  the  tracing  of  the  origin  and 
development  of  the  symptoms  of  the  psychopathic  malady. 
Important,  however,  as  the  following-up  of  the  history  or  of 

*Sidis:  An  Experimental  Study  of  Sleep,  JOURNAL  OF  ABNORMAL 
PSYCHOLOGY,  1908. 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State  125 

the  psychogenesis  of  the  symptoms  may  be,  both  to  the 
physician  and  to  the  patient,  for  an  intelligent  and  scientific 
comprehension  of  the  case,  it  does  not  cure,  as  some  are  apt 
to  claim,  the  psychopathic  malady.  The  value  of  tracing 
the  growth  of  the  disease  to  its  very  germs  lies  entirely  in  the 
insight  gained  into  the  nature  of  the  symptom-complex. 
The  tracing  of  the  psychogenesis  has  no  special  therapeutic 
virtues,  as  the  Germans  claim,  but,  like  all  theoretical  knowl- 
edge, is  of  the  utmost  importance  for  a  clear  understanding 
of  the  causation  of  the  psychopathic  state,  thus  helping  mate- 
rially in  the  treatment  of  the  case.  The  information  of  the 
psychogenesis  given  to  the  patient  is  valuable  only  in  so  far 
as  by  a  systematic  course  of  direct  and  indirect  suggestion, 
by  mediate  associative  and  immediate  associative  suggestion, 
by  substitution,  disintegration,  and  synthesis,  both  in  the 
waking  and  the  hypnoidal  states,  we  help  to  transform 
the  associative  course  and  emotional  tone  of  the  patient's 
mental  life.*  The  treatment  is  a  highly  complex  process 
of  disintegration  and  integration  of  mental  systems. 

From  a  practical  standpoint  the  therapeutic  value  of 
the  hypnoidal  state  is  by  far  the  most  important.  Now  as 
e  have  pointed  out,  our  experiments  on  sleep  have  revealed 
the  significant  fact  that  the  hypnoidal  state  is  the  primordial 
rest-state, —  sleep  is  but  a  derivative  form  of  rest.  In  many 
forms  of  diseases,  especially  nutritional,  it  is  often  advisable 
to  revert  to  a  more  simple  and  more  primitive  form  of  nutri- 
tion. Similarly  in  psychopathic  maladies  a  reversion  to 
a  simple  form  of  rest-state  proves  to  be  of  material  help  to 
the  patient.  In  plunging  the  patient  into  the  subwaking, 
hypnoidal  state  we  have  him  revert  to  a  primitive  rest-state 
with  its  consequent  beneficial  results.  The  suggestibility 
of  the  hypnoidal  state,  if  skilfully  handled,  increases  the 
therapeutic  efjicacy  of  the  hypnoidal  subwaking  state.  Re- 

*Sidis:    Psychopathological  Research;  Multiple  Personality;   Psycho- 
logy of  Suggestion, 


126  Psychotherapeutics 

laxation  of  nervous  strain,  rest  from  worry,  abatement  of 
emotional  excitement  are  known  to  be  of  great  help  in  the 
treatment  of  nervous  troubles  of  the  neurasthenic  or  of  the 
more  fashionable  psychasthenic.  We  find  something  simi- 
lar in  the  treatment  of  psychopathic  diseases  by  means  of  the 
agency  of  the  hypnoidal  state  the  therapeutic  efficacy  of 
which  is  all  the  more  heightened  by  the  presence  of  the  trait 
of  suggestibility.  Most  important,  however,  is  the  access 
gained  through  the  agency  of  the  hypnoidal  state  to  the  stores 
of  potential  subconscious  reserve-energy,  which,  by  a  liberation 
of  energy,  bring  about  a  reassociation  and  synthesis  of  the 
dissociated  mental  systems  underlying  the  symptoms  of  the 
disease.  The  therapeutic  value  of  the  hypnoidal  state  con- 
sists in  the  liberation  of  reserve  energy  requisite  for  the  syn- 
thesis of  the  dissociated  systems. 

The  theory  of  reserve  energy  is  of  the  utmost  importance 
to  abnormal  psychology.  The  theory  was  advanced  inde- 
pendently by  Prof.  Jamesf  and  myself,t  and  seems  to  me  to 
form  the  very  foundation  of  psychopathology  and  psycho- 
therapeutics.  It  is  by  no  means  easy  to  present  adequately 
the  principle  of  reserve  energy  in  this  brief  paper.  The 
principle  is  based  on  a  broad  generalization  of  facts,  psycho- 
logical, physiological,  and  biological,  namely,  that  far  less 
energy  is  utilized  by  the  individual  than  there  is  actually 
at  his  disposal.  In  fact,  but  a  very  small  fraction  of  the 
total  amount  of  energy  possessed  by  the  organism  is  used 
in  its  relation  with  the  ordinary  stimuli  of  its  environment. 
The  energy  in  use  may  be  regarded  as  the  kinetic  or  circulat- 
ing energy,  while  the  energy  stored  away  is  the  potential 
reserve  energy.  There  must  always  be  a  reserve  supply  of 
energy  requisite  for  unusual  reactions  in  emergency  cases. 
Those  organisms  survive  which  have  the  greatest  amount  of 

fjames:  The  Energies  of  Men,  Philosophical  Review,  1907. 
JSidis:   Studies  in  Psychopathology,  Ch.  xiv,  The  Principle  of  Reserve 
Energy,  B.  M.  S.  J.,  1907. 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State     12 J 

reserve  energy,  just  as  those  countries  are  stronger  and 
victorious  in  the  world-market  which  possess  the  largest 
amount  of  reserve  capital  to  draw  upon  in  critical  periods. 

As  life  becomes  more  complex  inhibitions  increase, — 
the  thresholds  of  stimulations  of  a  complex  system  rise  in 
proportion  to  its  complexity.  With  the  rise  of  evolution 
there  is  a  tendency  to  increase  of  inhibitions  with  a  conse- 
quent lock-up  of  energy  which  becomes  reserve.  Now  there 
are  occasions  in  the  life  of  the  individual,  under  the  influence 
of  training  and  emotional  trauma,  when  the  inhibitions 
become  unusually  intense  and  tend  to  smother  the  personality 
which  is  weakened,  impoverished  in  its  reactions,  and  is 
unable  to  respond  freely  to  the  stimuli  of  its  environment. 
The  inhibited  system  becomes  inactive  and  may  be  regarded 
as  dissociated  from  the  cycle  of  life.  In  case  of  an  emotional 
trauma  there  is  often  a  breach  in  continuity  of  association, 
the  affected  system  becomes  dissociated  from  the  rest 
of  mental  life,  and  is  like  a  splinter  in  the  flesh  of  the  indi- 
viduality. Its  own  threshold  when  tapped  may  be  very 
low,  but  is  not  directly  accessible  through  the  mediacy  of 
other  systems.  On  that  account  its  threshold  appears  unu- 
sually or  pathologically  high.  When  the  inhibitions  are 
very  high  they  must  be  removed.  This  removal  of  inhibi- 
tions brings  about  an  access  to  the  accumulated  energy  of  the 
inhibited  system.  In  case  of  disjunction  or  break  of  con- 
tinuity we  must  stimulate  the  reserve  dormant  energy  of 
the  systems  and  thus  assist  the  process  of  repair  and  bridge 
the  breach  of  associative  continuity.  A  new  fresh  active 
life  opens  to  the  patient.  He  becomes  a  different,  a  "  re- 
formed "  personality,  free  and  cheerful,  with  an  overflow  of 
energy. 

To  quote  from  a  former  work  of  mine:  * 
*  The  thresholds  of  our    psychophysiological    systems 
are  usually  raised,  mental  activity  working  in  the  course  of 

*Studies  in  Psychopathology,  B.  M.  S.  J.     1907. 


128  Psychotherapeutics 

its  development  and  growth  of  associative  processes  under 
ever  increasing  inhibitions  with  ever  higher  thresholds.  .  .  . 
On  account  of  the  high  thresholds  and  inhibitions  not  the 
whole  amount  of  the  psychophysiological  energy  possessed 
by  the  system  is  manifested;  in  fact,  but  a  very  small  portion 
is  displayed  in  response  to  stimuli  coming  from  the  habitual 
environment.  What  becomes  of  the  rest  of  the  unused 
energy  ?  It  is  stored,  reserve  energy. 

"  Biologically  regarded,  we  can  well  see  the  importance 
of  such  stored  or  reserve  energy.  In  the  struggle  for  ex- 
istence, the  organism  whose  energies  are  economically  used 
and  well  guarded  against  waste  will  meet  with  better  success 
in  the  process  of  survival  of  the  fittest,  or  will  have  better 
chances  in  the  process  of  natural  selection.  The  high  thres- 
holds and  inhibitions  will  prevent  hasty  and  harmful  reactions 
as  well  as  useless  waste  of  energy,  unnecessary  fatigue,  and 
states  of  helpless  exhaustion.  Moreover,  natural  selection 
will  favor  organisms  with  greater  stores  of  reserve  energy 
which  could  be  put  forth  under  critical  conditions  of  life.  In 
fact,  the  higher  the  organization  of  the  individual,  the  more 
varied  and  complex  the  external  environment,  the  more  valu- 
able and  even  indispensable  will  such  a  store  of  reserve 
energy  prove  to  be. 

'  The  course  of  civilization  and  education,  by  continu- 
ously raising  the  thresholds  and  inhibitions,  follows  the  line 
of  natural  selection  and  keeps  on  increasing  the  disposable 
store  of  potential,  subconscious  or  reserve  energy  both  in 
the  individual  and  the  race.  It  is  in  this  formation  of  an 
ever-greater  and  richer  store  of  disposable,  but  well-guarded, 
reserve  energy,  that  lies  the  superiority  of  the  educated  over 
the  uneducated  and  the  supremacy  of  the  higher  over  the 
lower  races. 

"  Civilization  and  education  are  processes  of  economy  of 
psycho-neural  force,  savings  of  mental  energy.  But  what 
society  is  doing^in  a  feeble  way  natural  selection  has  done 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State   129 

far  more  effectively.  What  education  and  civilization  are 
doing  now  on  a  small  scale  and  for  a  brief  period  of  time  the 
process  of  survival  of  the  fittest  in  the  ever-raging  struggle 
for  existence  has  done  for  ages  on  a  large  scale.  We  should, 
therefore,  expect  that  the  natural  reserve  energy  would  far 
exceed  that  of  the  cultivated  one. 

"  In  the  treatment  of  the  phenomena  of  psycho-physio- 
logical dissociation,  in  the  protean  symptoms  of  nervous 
and  mental  exhaustion  we  should  not  forget  this  biological 
principle  of  reserve  energy  and  should  make  attempts  to  use 
it.  In  many  cases  the  inhibitions  become  too  heavy  and  the 
thresholds  too  high.  We  must  loosen  the  grip  of  some  of  the 
inhibitions  and  lower  the  thresholds,  thus  utilizing  a  fresh 
supply  of  reserve  energy." 

A  similar  train  of  thought  was  developed  by  Dr.  S.  J. 
Meltzer  in  his  excellent  paper  on  "  The  Factors  of  Safety  in 
Animal  Structure  and  Animal  Economy."  *  By  a  striking 
series  of  instructive  facts  Dr.  Meltzer  points  out  that  "  All 
organs  of  the  body  are  built  on  the  plan  of  superabundance 
of  structure  and  energy."  I  cannot  resist  the  temptation  of 
quoting  Dr.  Meltzer's  conclusions  at  some  length  as  they  so 
clearly  elucidate  our  principle  of  reserve  energy  which  is  all 
the  more  valuable  as  Dr.  Meltzer  has  formulated  it  inde- 
pendently on  widely  different  grounds.  "  Of  the  supplies 
of  energy  to  the  animal  we  see  that  oxygen  is  luxuriously 
supplied.  The  supply  of  carbohydrates  and  fats  is  appar- 
ently large  enough  to  keep  up  a  steady  luxurious  surplus.  .  .  . 
The  liberal  ingestion  of  proteid  might  be  another  instance  of 
the  principle  of  abundance  ruling  the  structure  and  energies 
of  the  animal  body.  There  is,  however,  a  theory  that  in  just 
this  single  instance  the  minimum  is  meant  by  nature  to  be 
also  the  optimum.  But  it  is  a  theory  for  the  support  of  which 
there  is  not  a  single  fact.  On  the  contrary,  some  facts  seem 
to  indicate  that  Nature  meant  differently.  Such  facts  are, 

*Science,  1907. 


130  Psychotherapeutics 

for  instance,  the  abundance  of  proteolytic  enzymes  in  the 
digestive  canal  and  the  great  capacity  of  the  canal  for  absorp- 
tion of  proteids.  Then  there  is  the  fact  that  proteid  material 
is  stored  away  for  use  in  emergencies  just  as  carbohydrates 
and  fats  are  stored  away.  In  starvation  nitrogenous  pro- 
ducts continue  to  be  eliminated  in  the  urine  which,  accord- 
ing to  Folin,  are  derived  from  exogenous  sources,  that  is 
from  ingested  proteid  and  not  from  broken  down  organ 
tissues.  An  interesting  example  of  storing  away  of  proteid 
for  future  use  is  seen  in  the  muscles  of  the  salmon  before 
they  leave  the  sea  for  the  river  to  spawn.  According  to 
Mescher  the  muscles  are  then  large  and  their  productive 
organs  are  small.  In  the  river  where  the  animals  have  to 
starve  the  reproductive  organs  become  large,  while  the 
muscles  waste  away.  Here  in  time  of  affluence  the  muscles 
store  up  nutritive  material  for  the  purpose  of  maintaining 
the  life  of  the  animal  during  starvation  and  of  assisting  in 
the  function  of  reproduction.  This  instance  seems  to  be 
quite  a  good  illustration  of  the  role  which  the  factor  of  safety 
plays  also  in  the  function  of  the  supply  of  the  body  with 
proteid  food.  The  storing  away  of  proteid  like  the  storing 
away  of  glycogen  and  fat  for  the  use  in  expected  and  unex- 
pected exceptional  conditions  is  exactly  like  the  superabund- 
ance of  tissue  in  an  organ  of  animal  or  like  an  extra  beam 
in  the  support  of  a  building  or  a  bridge, —  a  factor  of  safety. 

"  It  seems  to  me  that  the  factors  of  safety  have  an  im- 
portant place  in  the  process  of  natural  selection.  Those 
species  which  are  provided  with  an  abundance  of  useful 
structure  and  energy  and  are  prepared  to  meet  many  emer- 
gencies are  best  fitted  to  survive  in  the  struggle  for  existence." 

The  hypnoidal  state  is  essentially  a  rest-state  character- 
ized by  anabolic  activity.  There  is  a  restitution  of  spent 
energy;  inhibitions  become  removed  and  access  is  gained 
to  what  Dr.  Prince  so  aptly  describes  as  "  dormant  "  systems 
or  complexes.  The  awakened  "  dormant  "  complex  systems 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State    131 

bring  with  them  a  new  feeling-tone,  a  fresh  emotional  energy 
resulting  in  an  almost  complete  transformation  of  personality. 

As  an  illustration  of  the  transformation  effected  I  take 
at  random  the  following  extracts  from  some  of  the  letters 
written  to  me  by  patients  who  have  experienced  this  welling 
up  of  reserve  energy: 

"  Indeed  were  I  to  fill  this  entire  sheet  with  expressions  of 
the  gratitude  which  wells  up  from  my  inmost  heart  it  would 
be  only  a  beginning  of  what  I  feel.  Surely  the  darkness  of 
the  world  has  been  dispelled  since  this  new  light  has  illumi- 
nated my  soul,  and  I  feel  that  this  wondrous  light  will  never 
fail  me.  It  were  vain  to  attempt  to  thank  you  for  this 
wonderful  transformation." 

Another  letter  reads:  '  You  will  be  glad  to  know  that 
all  is  well  with  me.  Life  is  one  happy  day,  I  am  a  marvel 
to  my  friends  in  the  way  of  happiness  and  cheer.  I  have  to 
confess  that  I  feel  almost  wicked  to  be  so  happy." 

Another  letter  runs  as  follows:  "  Next  to  the  gladness 
in  my  own  restoration,  I  am  rejoiced  at  the  wonderful  trans- 
formation that  has  come  to  my  dear  friend  T.  from  your 
marvelous  treatment.  She  writes  me  most  enthusiastically 
of  her  steady  and  sure  progress  toward  the  goal  of  perfect 
health,  of  her  strength  to  take  up  the  home  duties  which  had 
been  so  burdensome  and  which  she  now  finds  a  delight  in 
the  doing  of  them,  and  of  her  husband's  and  friends'  joy  in 
the  transformation  that  has  been  wrought  in  her." 

Dr.  Prince  in  his  "Unconscious"*  gives  an  extract  of  a 
patient's  letter  which  tells  of  a  similar  transformation  and 
awakening  of  dormant  reserve  energy.  "  Something  has 
happened  to  me  —  I  have  a  new  point  of  view.  I  don't  know 
what  has  changed  me  all  at  once,  it  is  as  if  scales  had  fallen 
from  my  eyes;  I  see  things  differently  —  you  have  given  me 
life  and  you  have  given  me  something  to  fill  it  with.  I  owe 

*  JOURNAL  OF  ABNORMAL  PSYCHOLOGY,  1909. 


132  Psychotherapeutics 

you  what  is  worth  far  more  than  life  itself,  namely  the  desire 
to  live." 

Those  extracts  are  typical  of  many  others  and  clearly 
show  the  enjoyment  of  new  strength  and  powers  until  now 
unknown  to  the  patient.  Fresh  levels  of  reserve  energy  have 
been  tapped  and  have  become  available  in  an  hour  of  dire 
need.  The  patient  has  light  and  strength  where  there  were 
darkness  and  depression.  We  are  confronted  here  with  the 
important  phenomenon  of  liberation  of  dormant  reserve 
energy.  The  patient  feels  the  flood  of  fresh  energies  as  a 
"  marvelous  transformation,"  as  a  "  new  light,"  as  a  "  new 
life,"  as  "  something  worth  far  more  than  life  itself." 

The  hypnoidal  state  helps  us  to  reach  the  inaccessible 
regions  of  dormant  energy,  it  helps  to  break  down  inhibitions, 
liberate  reserve  energies,  and  repair  the  breaches  of  mental 
activity.  The  painful  systems  become  dissociated,  disinte- 
grated and  again  transformed,  reformed,  and  reintegrated 
into  new  systems  full  of  energy  and  joy  of  life. 

It  is  quite  probable  that  Weir  Mitchell's  rest-cure  has 
derived  some  therapeutic  value  from  the  empirical  use  of  the 
subwaking  hypnoidal  rest-state.  Similarly  it  is  highly 
probable  that  Freud's  success  in  the  treatment  of  psycho- 
pathic cases  is  not  so  much  due  to  "  psycho-analysis,"  as  to  the 
unconscious  use  of  the  hypnoidal  state.  The  use  of  the 
hypnoidal  state  or  hypnoidization  has  been  recently  employed 
with  great  success  by  other  investigators,  among  whom  I  may 
mention  Dr.  John  E.  Donley,  who  has  made  a  valuable  con- 
tribution to  the  therapeutic  aspect  of  the  hypnoidal  state.* 
I  am  firmly  convinced  that  the  hypnoidal  state,  if  rightly  and 
intelligently  utilized,  will  prove  an.  important  factor  in  the 
domain  of  psychopathology  and  psychotherapeutics. 

Now  as  to  the  method  of  hypnoidization.  There  is 
nothing  rigid  about  the  method, —  it  admits  of  many  modi- 

*The  Clinical  Use  of  Hypnoidization,  JOURNAL  OF  ABNORMAL  PSY- 
CHOLOGY, 1908. 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State   133 

fications.  The  principal  object  consists  in  bringing  about 
the  conditions  of  monotony  and  limitation  of  voluntary 
movements  requisite  for  normal  and  abnormal  suggestibility. 
The  patient  is  put  in  a  relaxed,  recumbent  position;  he  is 
asked  to  put  himself  into  as  comfortable  a  position  as  pos- 
sible, close  his  eyes,  and  attend  to  some  monotonous  stimulus 
such  as  the  regular  beats  of  a  metronome  or  the  buzzing  of  an 
inductorium.  Gentle  massage  and  a  warm  bath  may  be  of 
material  help  in  excitable  cases.  Exercise,  fatigue  both 
physical  and  mental,  predisposition  to  sleep,  and  the  late 
hours  of  night  or  the  small  hours  of  morning,  are  favorable 
conditions.  When  respiration  and  pulse  become  reduced, 
sensory-motor  reaction  diminished,  sensory  hypoesthesia 
becoming  occasionally  hyperesthesia,  with  occasional  dis- 
turbances of  pulse  and  respiration,  with  sudden  apparently 
unaccountable  starts,  with  tendencies  of  retention  of  posi- 
tion of  limbs,  and  now  and  then  with  a  slight  tendency  to 
resist  actively  any  change  of  posture  of  limbs  or  of  body 
without  the  actual  presence  of  catalepsy,  the  whole  feeling 
tone  becoming  one  of  acquiescence  and  indifference,  while 
memory  with  amnesic  gaps  begins  to  find  the  lost  links  and 
even  to  become  hypermnesic, —  when  we  observe  all  those 
symptoms  we  know  we  have  before  us  the  subconscious  hyp- 
noidal  state.*  Pneumographic  tracings  taken  at  the  same 
time  help'to  detect  the  state,  characteristic  by  the  numerous 
transient  ^changes  and  the  various  oscillations  of  depth  of 
level  which  take  place  in  this  unstable  subwaking  state, 
intermediate  as  it  is  between  the  waking  state  on  the  one 
hand,  sleep  and  hypnosis  on  the  other. 

From  this  general  discussion  about  the  nature  of  the 
hypnoidal  state  and  the  methods  of  its  induction  we  may 

* "  The  subconscious,"  notwithstanding  the  ill-based  attacks  now 
fashionable  among  some  psychologists,  forms  the  very  foundation  of  psy- 
chopathology.  The  subconscious  is  as  vital  and  essential  in  psycho- 
pathology  as  "ether"  is  in  physics.  I  shall  discuss  this  subject  in  its  proper 
place. 


134  Psychotherapeutics 

now  turn  to  a  brief  review  of  some  of  the  cases  treated  by 
hypnoidization.  The  tracing  of  the  growth  and  development 
of  the  various  symptoms  by  means  of  the  memories  restored 
in  the  hypnoidal  state  is  here  omitted,  as  the  object  of  the 
present  paper  is  not  the  study  of  the  causation  and  origin 
of  the  psychopathic  systems  or  "  complexes,"  but  rather 
their  reassociation  and  cure  effected  by  the  reserve  energies 
liberated  in  the  hypnoidal  state.  I  give  cases  of  partial  as 
well  as  complete  success  so  as  to  give  the  reader  a  more  or 
less  adequate  notion  of  the  therapeutic  value  of  the  treatment. 
Cases  of  partial  success  are  presented  first. 

I.  Miss  P.  R.  Age  23.  American.  Mother  is  very 
nervous.  Sister  is  "  high  strung."  Father  is  well.  When 
young,  patient  was  regarded  as  sensitive.  Her  present 
trouble  began  three  years  ago.  She  suffers  from  digestive 
disturbances,  dizziness,  circulatory  irregularities,  numbness 
in  hands  and  legs,  and  especially  from  continuous  feeling 
of  fatigue.  Her  sleep  is  restless,  she  dreams  a  good  deal. 
Attention  is  good,  but  her  mental  state  is  one  of  indecision. 
If  left  to  herself,  she  would  remain  in  the  same  place.  To 
make  a  change  in  her  surroundings  is  hard  and  painful  to 
her.  The  fear  of  meeting  people  and  specially  strangers  is 
quite  intense;  in  fact,  it  constitutes  her  central  obsession.  At 
the  age  of  eighteen  she  fell  in  love  with  a  young  man  to  whom 
she  became  engaged.  A  year  later  the  engagement  was 
broken  off  under  very  distressing  circumstances.  Since  then 
the  present  condition  has  gradually  developed.  The  patient 
was  in  a  chronic  state  of  mental  depression  and  was  not  un- 
aware of  the  real  origin  of  her  trouble,  but  the  awareness 
was  vague,  often  falling  below  the  margin  of  clear  conscious- 
ness. 

The  patient  expected  to  be  hypnotized,  but  she  could 
not  go  into  hypnosis.  After  a  few  trials  at  hypnotization  the 
hypnoidal  state  was  used.  At  first  the  hypnoidal  state  was 
brief  in  duration,  but  with  its  repetition  it  became  prolonged 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State   135 

and  deepened  with  gradually  increasing  beneficial  effects. 
The  patient  was  but  three  weeks  under  my  care.  She  felt 
greatly  improved  and  returned  home  before  the  recovery  was 
made  complete. 

II.  Mr.  A.  C.  Actor.  Age  47.  American.  There 
are  no  special  diseases  in  the  family  except  "  nervousness." 
The  patient  is  imaginative  and  emotional.  When  about  the 
age  of  ten  his  grandfather  gave  him  Faust  to  read.  Since 
then  he  has  been  troubled  with  the  insistent  idea  of  having 
sold  his  soul  to  Satan.  In  his  childhood  he  was  very  reli- 
gious,—  prayed  much,  was  afraid  of  sins,  and  suffered  from 
nightmares.  About  fifteen  years  ago  had  syphilis,  for  which 
he  was  treated  for  a  period  of  two  years.  Up  to  the  age  of 
32  patient  led  a  gay  life.  Seven  years  ago  he  suddenly 
felt  that  "  something  snapped  in  his  head  "  and  he  became 
greatly  frightened.  He  thought  it  was  paresis  or  tabes, 
"  as  so  many  actors  suffer  from  those  diseases."  This  fright, 
however,  soon  wore  off.  A  month  later,  after  a  strenuous 
and  fatiguing  series  of  plays,  he  suddenly  woke  up  in  the 
middle  of  the  night  with  the  idea  of  paresis  and  intense  fear. 
The  overconscientiousness  and  fear  of  sin  characteristic  of 
his  childhood  and  boyhood  have  now  reappeared,  and  he  is 
obsessed  by  the  fear  of  sin,  deception,  blasphemy.  He 
suffers  from  vague  pains  all  over  the  body  and  from  digestive 
disturbances,  but  he  is  specially  obsessed  by  the  fear  of 
parasyphilitic  diseases,  tabes  and  paresis,  the  symptoms 
of  which  are  reflected  in  his  attacks. 

In  the  hypnoidal  state  he  became  quieted,  much  of 
the  fear  and  depression  was  gone.  In  addition  to  other 
information  obtained,  though  interesting  from  a  psycho- 
pathological  standpoint,  space  does  not  permit  to  give  here, 
it  was  found  that  the  last  attack  was  occasioned  by  a  long 
visit  to  a  friend  of  his,  also  an  actor,  who  suffered  from 
gastric  crises  of  tabes.  A  series  of  treatments  by  hypnoidiza- 


136  Psychotherapeutics 

tion  improved  considerably  the  patient's  condition,  and  he 
returned  to  his  occupation,  which  he  could  not  possibly 
give  up  for  any  length  of  time. 

III.  Mr.  C.  S.     Age  39.     Russian.     Builder.    Father 
died  of  apoplexy  at  the  age  of  72.     Mother  is  77,  but  has 
always  been  nervous.     Brothers  and   sisters  are  well.     Pa- 
tient is  rather  undersized  and  weighs  ninety-seven  pounds. 
He  is  very  emaciated,  looks  cachectic,  suffers  from  anorexia, 
nausea,  indigestion,  and  from  vague  abdominal  pains.     De- 
tailed inquiry  into  the  patient's  sexual  life  disclosed  no  ab- 
normality.    Anything    unpleasant    awakens    a    feeling    of 
nausea.     This  can  be  traced  to  an  infectious  disease  from 
which  the  patient  suffered  some  twelve  years  ago.     He  was 
frightened   over   it   and   worried    about   the   consequences. 
Nausea  and  vomiting  were  present  during  the  course  of  the 
disease  and  persisted  afterwards.     The  patient  is  introspec- 
tive and  suggestible  in  regard  to  sickness.     If  any  of  the 
family  happen  to  have  any  trouble,  he  is  sure  to  fall  sick 
with  the  same  symptoms.     Thus  about  two  months   ago 
the  patient's  mother  fell  and  broke  her  left  arm,  he,  too,  soon 
began  to  feel  pain  in  the  left  arm,  for  which  he  had  to  be 
treated.     Every  new   moon   he   experiences   intestinal   dis- 
turbances, because  about  that  time,  in  his  childhood,  his 
mother  used  to  administer  to  him  a  purgative. 

Put  into  the  hypnoidal  state  patient  felt  much  relieved. 
The  beneficial  results  of  the  treatment  became  manifested 
at  the  end  of  a  few  weeks. 

IV.  Mr.  M.  G.     Irish.     Age  38.     Married.    Occupa- 
tion, liquor  dealer.     Father  alive  and  well.     Mother  died 
of  pneumonia  at  the  age  of  forty.     Brother  and  sister  died 
of  some  obscure  form  of  "  heart  trouble."     Physical  con- 
dition is  good.     Patient  has  no  appetite,  worries,  has  no 
confidence  in  himself.     He  is  extremely  methodical,  things 
must  be  arranged  in  certain  order  or  he  feels  uneasy  and 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State   137 

quite  unhappy.  Has  no  headaches,  but  suffers  from 
insomnia.  Does  not  drink,  but  smokes  excessively.  Sexual 
life  normal.  Has  been  sensitive  and  nervous  from  his  very 
childhood.  He  broods  much  over  his  incapacity  of  spelling. 
Has  been  lately  working  very  hard  on  a  new  business  intrusted 
to  his  care.  He  doubts  his  business  capacities  and  fears  to 
ruin  the  business.  He  became  greatly  depressed  and  had  to 
give  up  his  work  and  go  to  the  country,  but  with  no  beneficial 
results. 

The  patient  was  brought  to  me  in  a  state  of  deep  de- 
spondency, close  on  the  brink  of  suicide.  He  could  not  be 
hypnotized.  I  put  him  into  a  hypnoidal  state,  kept  him  in 
a  state  of  relaxation  for  fifteen  minutes.  When  he  came  out 
of  it  he  felt  "  a  little  better,  but  not  much."  After  two 
weeks'  treatment  the  patient  felt  so  far  improved  that  I  ad- 
vised him  to  return  to  his  work,  while  the  treatment  was 
being  continued.  Gradually  his  despondency  gave  way, 
his  worries,  fears,  and  doubts  disappeared,  and  confidence  in 
himself  became  strengthened.  Patient  declared  he  "  never 
felt  so  well  before."  The  treatment  covered  a  period  of 
three  months.  It  is  now  more  than  two  years,  the  patient 
continues  to  be  in  excellent  condition. 

V.  Mrs.  J.  F.  Age  28.  American.  Married.  Family 
history  good.  For  many  years  patient  has  been  suffering  from 
severe  headaches,  backache,  general  fatigue,  and  weakness 
of  the  eyes  which  occasionally  became  intolerably  painful. 
The  headaches  became  sometimes  so  intense  that  the  patient 
suffered  agonies.  The  pains  extended  all  over  the  head 
and  even  down  the  arms  and  back.  There  were  present 
sore  spots  in  the  back  of  the  head,  the  pressure  on  which 
somewhat  relieved  the  pain.  Various  pains  of  a  more 
indefinable  character  were  also  complained  of  in  the  right 
ovarian  region,  pains  which  increased  on  exercise.  The 
patient  had  usually  no  appetite,  nothing  tasted  well, —  there 


138  Psychotherapeutics 

was  some  unpleasant  odor  in  the  food;  nutrition  was  poor. 
Occasionally  she  suffered  from  bulimia  alternating  with 
anorexia.  The  sense  organs  were  hyperesthetic;  field  of 
vision  was  normal.  The  heart  was  normal,  though  occa- 
sionally irregularity  of  heart-beat  could  be  observed,  due 
to  the  patient's  extreme  nervousness.  A  gynecologist 
diagnosed  salpingitis  and  advised  an  operation  on  account 
of  adhesions  formed.  The  patient,  however,  refused 
to  be  operated  on,  and  the  family  physician  carried  out 
a  long  course  of  gynecological  treatment.  The  oculist 
treated  her  eyes,  and  after  a  long  examination  and  treatment 
fitted  her  with  glasses;  but  the  eyes  were  no  better  and 
the  headaches  were  as  severe  as  before. 

After  a  fair  trial  had  been  given  to  various  treatments 
I  had  to  resort  to  hypnoidization.  A  year's  treatment  by 
the  hypnoidal  state  made  the  symptoms  disappear.  The 
patient  gained  in  flesh  and  in  strength,  and  felt,  as  she  put  it, 
"  younger  than  ever." 

VI.  Miss  G.  A.  Age  55.  American.  Three  brothers 
died  of  various  forms  of  cardiac  affections.  Father  died  of 
pneumonia;  mother  died  of  fatty  degeneration  of  the  heart. 
One  of  the  sisters  suffered  from  akromegaly  and  died  of 
heart  trouble.  There  are  histories  of  tuberculosis  in  the 
collateral  branches  of  the  family.  Patient  looks  poorly 
nourished,  her  appetite  is  completely  gone.  She  suffers 
from  insomnia,  headaches,  backache,  general  diffused  pains 
all  over  the  body;  complains  of  lassitude  and  of  lack  of 
interest  in  what  goes  on  around  her.  She  feels  despondent 
and  has  crying  spells.  The  depression  reaches  such  an  acute 
stage  that  the  patient  is  afraid  of  losing  her  mind.  When  a 
child  she  suffered  from  pavor  nocturnus  and  when  about  the 
age  of  twelve  she  took  a  long  fatiguing  journey  which  brought 
on  such  a  state  of  exhaustion  that  on  her  return  she  became 
aphasic  and  hemiplegic  and  was  confined  to  bed  for  six 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State     139 

months.  The  present  condition  set  in  a  few  years  ago, — 
she  lost  the  sense  of  smell  and  of  taste,  while  she  fell  into  a 
state  of  deep  depression.  Neurologists  regarded  her  as  a 
case  of  some  obscure  "  neurosis,"  obstinate  and  incurable. 

I  must  confess  that  when  I  undertook  the  case  I  did  not 
expect  any  favorable  results.  It  was  an  old,  chronic,  insidi- 
ous case.  The  age  of  the  patient,  the  apparent  obscurity  of 
the  trouble,  as  well  as  the  family  history  were  by  no  means 
encouraging.  The  patient  did  not  go  into  a  hypnotic  state 
and  I  had  to  use  the  hypnoidal  state.  The  first  couple  of 
months  the  treatment  dragged  along  indifferently.  All  I 
could  then  say  was  that  the  patient  did  not  get  worse  under 
the  treatment.  The  hypnoidal  state,  however,  gradually 
admitted  me  into  the  patient's  early  history,  and  I  obtained 
important  clues  to  her  symptoms.  Here  comes  in  the  value 
of  a  knowledge  of  the  course  and  the  development  of  the 
malady  and  the  consequent  help  in  the  therapeutic  treatment 
of  the  dissociated  systems.  With  a  better  insight  into  the 
abnormal  psychology  of  the  case  the  hypnoidal  state  could  be 
used  to  better  advantage.  The  patient  began  to  improve 
rapidly  and  at  the  end  of  the  fourth  month  of  treatment  by 
hypnoidization  completely  recovered.  It  is  now  more  than 
four  years  since  the  end  of  the  treatment,  and  I  may  say  that 
the  patient  has  not  had  a  single  relapse, —  she  continues  to 
stay  well;  she  has  become  an  energetic  social  worker,  greatly 
valued  for  her  indomitable  energy  as  well  as  cheerfulness  of 
mind.  People  who  know  her  say  that  "  wherever  she  goes 
she  brings  sunshine  with  her."  A  new  life  was  awakened 
in  her.  The  subconscious  reserve  energy  which  has  remained 
dormant  in  her  for  so  many  years  has  become  unlocked  and 
utilized  in  her  ordinary  daily  life. 

VII.  MissA.W.  Age  35.  Irish.  Housekeeper.  Physical 
condition  is  good.  Occasionally  suffers  from  cephalalgia, 
but  on  the  whole  headaches  do  not  trouble  her.  She  suffers 
often  from  auditory  hallucinations,  thinks  she  is  possessed 


140  Psychotherapeutics 

by  demons.  From  her  ninth  year  she  had  hallucinations  of 
spirit  voices  which  tell  her  very  unpleasant  things.  The 
auditory  hallucinations  are  accompanied  by  attacks  of 
automatic  speech.  It  seems  to  the  patient  as  if  another 
being  forces  her  to  tell  what  she  thinks.  It  is  on  that  account 
that  she  shuns  her  friends  and  acquaintances.  Occasionally 
she  has  visual  hallucinations  of  angels  and  saints. 

It  would  take  too  much  space  to  give  an  account 
of  this  interesting  case.  We  can  only  refer  here  to  this  case 
in  its  main  outlines.  Our  object  is  not  the  psychopatho- 
logical,  but  the  psychotherapeutic  aspect  of  the  cases. 

The  patient  could  not  be  hypnotized,  but  she  went  easily 
into  the  hypnoidal  state.  At  first  the  improvement  was 
rather  slight.  In  fact,  now  and  then  the  hallucinations  and 
the  automatic  speech  became  even  more  frequent  and  more 
annoying  than  before.  In  a  couple  of  months,  however, 
the  outlook  began  to  be  brighter,  the  auditory  and  visual 
hallucinations  began  to  give  way.  The  automatic  speech 
considerally  diminished,  and  after  a  few  months  the  symptoms 
completely  disappeared. 

In  the  control  of  alcoholism  the  treatment  by  hypnoi- 
dization  yields  extremely  satisfactory  results.  The  principle 
of  subconscious  reserve  energy  stands  out  clear  and  distinct 
in  such  cases.  We  shall  return  to  this  aspect  of  psychothera- 
peutics  in  its  proper  place,  our  object  here  is  simply  to  bring 
out  the  therapeutic  value  of  the  hypnoidal  state. 

VII.  Mr.  G.  S.  American.  Single.  Age  37.  Family 
history  is  good, —  except  that  one  maternal  uncle  was  a 
victim  of  drink  habit.  A  physical  examination  shows  an 
irregular  heart  due  to  nervousness,  excessive  smoking.  Liver 
is  enlarged  and  cirrhotic.  The  patient  was  brought  to  me 
just  after  a  debauch,  was  nervous,  shaky,  with  quite  an  ex- 
tensive tremor  of  the  hands.  He  began  to  drink  when  in 
school  as  a  matter  of  boon  companionship  and  has  since 
become  addicted  to  drink.  He  kept  at  it  regularly,  at  times 
actually  soaking  in  alcohol.  The  family  induced  him  to 


The  Psychotherapeutic  Value  of  the  Hypnoidal  State    141 

try  the  treatment  of  various  establishments  for  the  cure  of 
alcoholics,  but  with  no  appreciable  results.  As  soon  as  he 
left  the  sanitarium  he  immediately  went  off  on  a  debauch. 
He  suffered  a  few  times  from  severe  attacks  of  delirium 
tremens.  The  patient  was  in  such  a  bad  state  that  he 
wanted  his  share  of  property  to  devote  the  remainder  of 
his  life  to  drink. 

Under  a  rigorous  treatment  by  the  hypnoidal  state  the 
patient  ceased  drinking,  lost  all  craving  for  liquor.  His 
physical  and  mental  condition  grew  in  strength.  After  a 
few  months'  treatment  he  was  enabled  to  return  to  his  busi- 
ness. The  man  has  become  completely  reformed.  He  is 
now  manifesting  an  intense  activity,  great  devotion  to  and 
steadiness  in  his  work.  No  one  suspected  in  him  such 
capacities  of  foresight  and  energy  in  business  management. 
New  stores  of  subconscious,  dormant  reserve  energy  have 
welled  up  from  the  depths  of  his  being.  He  has  become 
a  different  man.  His  own  brothers  are  surprised  at  the 
radical  transformation  of  his  character. 

VIII.  Mr.  J.  L.  Irish.  Protestant.  Age  57.  Family 
history  is  good,  except  for  the  fact  that  his  brother  is '  also 
addicted  to  drink  and  was  under  my  care  for  a  few  weeks, 
with  the  result  that  he  left  off  drink  for  two  years.  Patient 
is  a  printer  by  trade  and  has  been  drinking  for  over  thirty 
years.  While  he  is  usually  kind  natured,  when  under  the 
influence  of  drink  he  is  violent,  abusive,  offensive  to  his  wife 
and  children,  who  are  afraid  of  him.  From  his  sister  and  wife 
I  have  the  information  that  the  patient  goes  off  periodically 
on  a  long  spree  and  spends  all  his  money,  neglecting  his  wife 
and  children;  when  he  comes  home  he  abuses  everybody 
in  the  house.  '  It  is  not  a  home,  it  is  a  hell,"  as  his  sister 
puts  it.  In  his  better  moments  the  patient  himself  admits 
he  is  a  brute,  that  drink  has  the  best  of  him.  He  must 
keep  away  from  drink  completely,  because  the  mere  taste  of 
it  sets  him  going.  An  examination  reveals  the  presence  of 
arteriosclerosis. 


142  Psychotherapeutics 

I  attempted  to  put  the  patient  into  the  hypnotic  state, 
but  I  found  the  hypnoidal  state  would  meet  with  less  re- 
sistance and  suspicion  on  the  side  of  the  patient.  Hypnoi- 
dization  then  was  the  order  of  the  day.  The  patient  began  to 
improve,  was  less  nervous,  slept  better,  and  what  was  more 
important,  stopped  drinking,  lost  all  craving  for  liquor. 
After  three  weeks  of  treatment  by  means  of  hypnoidization 
the  patient  was  discharged.  He  did  not  drink  for  a  whole 
year,  but  coming  in  contact  with  other  workmen  in  the  union 
he  was  invited  to  drink,  could  not  refuse,  and  once  more  was 
started  on  his  old  career.  He  came  back  to  me,  and  this 
time  I  treated  him  daily  for  a  month.  Throughout  the 
treatment  the  hypnoidal  state  was  used.  The  patient  has 
given  up  his  drink  habit,  has  no  craving  for  liquor,  works 
regularly  at  his  job  and  no  longer  associates  with  companions 
who  are  given  to  drink.  His  sister  and  wife  keep  me  regu- 
larly informed  about  his  condition,  and  the  report  for  the  last 
two  years  has  been  "  John  is  very  good,  he  is  a  gentleman, 
treats  the  children  well."  He  has  become  a  model  father  and 
a  good  husband. 

IX.  Mr.  C.  T.  Age  32.  American.  Father  was  an 
inveterate  drunkard  and  was  drowned  while  in  a  state  of 
intoxication.  A  maternal  as  well  as  a  paternal  uncle  were 
confirmed  drunkards.  There  was  also  drunkenness  in  the 
collateral  branches  of  the  family.  The  patient  learned  to 
drink  when  very  young.  His  mother,  who  volunteered  the 
information,  told  me  that  she  suspected  that  her  son  began 
to  drink  wine  at  the  age  of  seven.  Since  that  time  the  drink- 
obsession  grew  on  him  and  he  became  a  confirmed  drunkard 
at  the  age  of  twenty.  The  patient's  physical  condition  is 
good.  The  emotional  state  is  one  of  passive  indifference, 
the  intellectual  activities  are  rather  in  abeyance,  the  general 
disposition  is  inoffensive  and  even  mild.  It  seems  that  the 
alcohol  has  soaked  out  of  him  all  his  strength.  He  has  no 
ambition  and  is  not  fit  to  do  anything,  as  he  is  constantly 
under  the  influence  of  liquor.  His  will  power  is  weak,  he 


The  Psychotherapeutlc  Value  of  the  Hypnoidal  State   143 

has  no  sense  of  personal  responsibility,  and  nothing  of  any 
importance  can  be  intrusted  to  him.  Socially  he  is  ostra- 
cized by  his  relatives,  but  he  seems  to  mind  it  little. 

Considering  the  family  and  personal  history  of  the  case 
I  was  not  enthusiastic  over  the  outcome  of  the  treatment. 
The  family,  however,  insisted  on  treatment  and  the  mother 
was  anxious  to  have  me  undertake  the  case  as  he  was  her 
only  son.  The  treatment  lasted  for  about  a  year  and  was 
carried  out  by  means  of  the  hypnoidal  state.  To  my  great 
surprise  and  contrary  to  my  expectations  the  patient  has 
given  up  his  drink.  He  changed  so  much  that  even  his 
mother  wondered  at  the  transformation.  From  being 
apathetic  he  became  ambitious,  from  being  dependent  he 
became  self  reliant.  He  manifested  a  self  control  which 
none  of  his  intimate  friends  ever  suspected  in  him.  He 
became  methodical,  systematic,  conscientious  in  his  work, 
and  displayed  an  unusual  ability  in  management.  From 
being  weak,  irregular,  and  unreliable,  his  character  became 
energetic,  firm,  and  trustworthy.  His  abilities  were  soon 
noticed,  appreciated,  and  he  has  since  become  a  manager  of 
a  large  concern.  Nowhere  have  I  observed  such  limitations, 
such  moral  innrmity,  such  lack  of  capacity,  change  so  radi- 
cally to  strength  of  will  combined  with  a  sense  of  personal 
responsibility  and  vigor  of  intellectual  activity.  Since  then 
I  began  strongly  to  doubt  the  so-called  fatal,  hereditary 
dipsomania  of  psychiatric  text-books.  I  must  say  that  I 
now  completely  disbelieve  that  medico-calvinistic  doctrine 
of  "total  inability  and  damnation,"  in  regard  to  dipsomania. 
There  may  be  hereditary  tendencies  to  nervous  instability, 
tendencies  to  excitement  with  consequent  craving  for  stimuli 
inducing  exaltation,  but  certainly  there  is  no  hereditary 
alcoholism.  What  sort  of  stimuli  a  person  is  sensitive  to 
depends  on  training  and  environment.  It  may  be  art,  science, 
politics,  religion,  or  drink.  There  is  no  more  hereditary 
dipsomania  than  there  is  congenital  gambling.  From  a  mere 


144  Psychotherapeutics 

anamnesis  no  snap  prognosis  should  be  made  without  giving 
the  case  a  good  trial  and  proper  treatment;  no  alcoholic  pa- 
tient should  be  declared  as  hopeless. 

With  the  advance  of  my  psychopathological  studies 
and  psychotherapeutic  work  I  begin  to  have  more  confidence 
in  the  principle  of  dormant  reserve  energy  and  have  more 
trust  in  the  therapeutic  value  of  the  hypnoidal  state. 


OBSESSIONS  AND  ASSOCIATED  CONDITIONS  IN 
SO-CALLED  PSYCHASTHENIA 

BY  JOHN  E,  DONLEY,  M.D. 

Physician    for   Netvous   Diseases,    St.    Joseph's   Hospital, 
Providence,  R.  I. 


OBSESSIONS  AND  ASSOCIATED  CONDITIONS  IN 
SO-CALLED  PSYCHASTHENIA 

BY  the  term  obsession  I  shall  understand  any  recurring, 
extra-voluntary   idea,    feeling,   or    emotion   which 
presents  itself  automatically  in  consciousness,  either 
alone  or  in  combination;  and  the  clinical  syndrome 
characterized  essentially  by  such  obsessions  and  associated 
states,  I  shall,  following  many  others,  call  psychasthenia. 
As  psychotherapeutists  we  are  interested  in  obsessions,  not 
only  as  to  their  content,  that  is  to  say,  the  particular  form  and 
character  they  assume,  but  also  and  equally,  if  not  indeed 
chiefly,  as  to  their  mechanism, —  the  manner  in  which  they 
arise,  the  factors  by  which  they  are  perpetuated,  and  the 
methods  whereby  they  may  be  either  alleviated  or  cured. 

Approaching  the  subject,  then,  from  this  angle,  we  may 
set  out  with  the  observation  that  every  obsession  has  its 
history  just  as  truly  as  has  a  painting,  a  poem,  or  a  symphony. 
Obsessions  are  not,  therefore,  as  is  so  often  apparently  be- 
lieved, discontinuous  and  uncaused  mental  experiences, 
arising  nowhere  and  disappearing  no  whither;  they  are  just 
as  much  products  as  are  any  other  of  the  contents  of  con- 
sciousness; and  only  in  this  are  they  sui  generis,  that  they 
are  products  of  a  very  special  and  peculiar  kind,  whose 
genesis  it  may  or  may  not  be  within  our  power  to  discover. 
To  seek  out  the  psycho-genetic  mechanism  of  obsessions  is 
accordingly  the  first  step  toward  a  rational  psychotherapy; 
for  only  if,  and  in  so  far  as,  a  careful  inquiry  of  this  sort  has 
been  preliminary  to  any  attempt  at  therapeusis,  can  the  latter 
hope  to  be,  in  some  manner  and  degree,  successful. 

The  pursuit  of  this  genetic  method  leads  straight  into 
the  complexities  and  difficulties,  sometimes,  indeed,  into  the 
frustrations  of  normal  and  abnormal  psychology.  Yet,  how- 
ever difficult  this  domain  may  appear  to  be,  to  enter  it  is  an 
absolute  prerequisite  to  the  progressive  treatment  of  psy- 
chasthenia. 

H7 


148  Psychotherapeutics 

The  most  striking  attribute  of  obsessive  mental  states 
is  their  more  or  less  constantly  recurring  automatism.  They 
do  not  appear  as  normal  and  harmonious  elements  within 
the  conscious  stream;  on  the  contrary  they  are  intruders 
whose  constant  entrance  and  exit  disrupt  the  customary 
processes  of  mental  life.  In  the  language  of  abnormal 
psychology,  they  are  said  to  arise  as  mental  states  or  com- 
plexes which  have  been  dissociated  or  split  off  from  the  main 
stream  of  the  self-conscious  personality.  Whether  an  obses- 
sion appears  in  consciousness  as  a  complex  whose  nucleus  is 
an  idea,  a  feeling,  or  an  emotion,  it  is  to  be  looked  upon  as 
having  its  origin  in  the  same  psychological  mechanism, 
namely,  dissociation.  The  psychological  details  of  this 
dissociation  may  vary  within  comparatively  wide  limits  in 
particular  obsessions,  but  the  general  underlying  principle 
would  appear  to  be  the  same  in  all. 

In  the  evolution  of  an  obsession,  dissociation  is  but  one 
aspect  of  the  process;  for  association  comes  to  play  an  equally 
important  role  in  the  drama.  Given  a  dissociated  mental 
element,  whether  idea,  feeling,  or  emotion,  this  mental  ele- 
ment will  not  for  long  remain  isolated  and  unattached,  but 
in  accordance  with  the  laws  of  association  will  connect  itself 
with  some  other  conscious  content  to  form  a  definite  com- 
plex, upon  the  character  of  which  will  depend  the  type  of 
obsession  which  appears  in  consciousness;  for  obsession  is  just 
another  name  for  a  particular,  actively  functionating  complex. 

Now  this  obsessive  complex  may  be  of  multifarious 
composition;  it  maybe  composed  chiefly  of  ideational,  feeling, 
or  emotional  constituents;  it  may  be  thick  or  thin,  wide  or 
narrow;  it  may  contain  many  elements  or  few;  as  time  goes 
on  it  may  function  in  its  original  integrity  or  may  become 
split,  thus  giving  rise  to  curious  and  perplexing  clinical 
manifestations;  finally,  the  complex  may  be  wholly  or  only 
partially  conscious  or  subconscious;  or  to  state  it  another 
way,  the  obsessed  individual  may  be  aware  of  much  or  of 


Conditions  in  Psychasthenia  149 

little  concerning  that  which  is  really  operative  in  the  produc- 
tion of  his  abnormal  mental  condition. 

We  said  a  moment  ago  that  association  plays  an 
equally  important  part  with  dissociation  in  the  mechanism 
of  obsessions.  Obviously  it  is  impossible  here  even  to  name 
the  numberless  associations  that  may  occur  between  the 
conscious,  subconscious,  and  co-conscious  levels  of  mind, 
and  the  various  obsessive  complexes  which  may  thus  arise. 
One  may  point  out,  however,  the  important  fact  that  these 
associations  may  be  found  to  have  taken  place  not  only 
between  ideas  as  such,  but  also  between  any  and  all  of  the 
other  elements  of  consciousness,  as  well  as  between  these 
latter  and  purely  physiological  processes,  such  as  those 
mediated  by  the  voluntary  and  involuntary  musculature  and 
by  glands.  Thus  it  may  be  seen  that  the  variety  of  obses- 
sions is  coterminous  with  the  possibilities  of  abnormal  asso- 
ciation and  dissociation;  hence  also  the  impossibility  of 
placing  a  limit  to  the  patterns  according  to  which  obsessions 
may  be  formed. 

When  once  an  obsessive  complex  has  been  definitely 
established,  it  may  be  roused  to  future  activity  in  a  variety 
of  ways.  What  I  desire  especially  to  call  attention  to  here 
is  the  law  of  the  substitution  of  stimulus,  which  may  often- 
times explain  the  active  functioning  of  an  otherwise  most 
puzzling  obsession.  Suppose  the  case  where  a  person  has 
had  a  painful  and  emotionally  upsetting  experience  with  a 
cat.  Out  of  this  experience  may  arise  an  obsessive  complex, 
namely,  fear  of  cats.  In  order  to  arouse  this  complex  to 
activity,  it  is  not  necessary  in  the  future  to  experience  the 
actual  presence  of  a  cat.  All  that  is  required  is  some 
stimulus,  e.g.,  the  mere  word  cat,  that  has  a  symbolic  rela- 
tionship with  the  original  experience.  Or  take  the  case  of 
a  patient  of  mine  who  overheard  the  doctors  at  a  consultation 
remark  that  a  certain  pathological  condition  in  her  breast 
might  be  a  carcinoma.  As  a  matter  of  fact  it  turned  out  to 


150  Psychotherapeutics 

be  nothing  of  the  sort,  yet  the  qosessive  fear  of  carcinoma  of 
the  breast  remained  with  her  for  many  months.  In  order  to 
rouse  her  obsession  it  was  necessary  merely  to  present  to  her 
something  having  a  direct  or  indirect  symbolic  relationship 
with  the  breast.  On  one  occasion  she  was  calling  upon  a 
friend  who  had  recently  given  birth  to  a  daughter.  Out  of 
the  clear  sky  of  conversation  came  something  about  the  nurs- 
ing of  the  child,  when  straightway  an  attack  of  obsession 
occurred  which  compelled  her  to  terminate  the  visit.  If  we 
bear  this  fact  of  substitution  of  stimulus  well  in  mind  we 
may  perhaps  be  able  to  explain  an  otherwise  perplexing 
assault  of  obsessions. 

Enough  has  now  been  said  perhaps  to  give  a  reasonably 
clear  idea  of  the  psycho-genesis  of  obsessions, —  their  origin 
usually  in  some  previous  experience  of  the  individual,  which 
experience  is  either  not  remembered  at  all,  or  if  so,  is  not 
recognized  as  being  the  point  of  departure  for  the  obsession; 
their  formation  through  dissociation  of  certain  mental  ele- 
ments and  the  subsequent  association  of  these  elements  with 
other  contents  of  consciousness  to  form  an  obsessive  complex; 
and  finally  the  automatic  and  recurrent  functioning  of  the 
complexes  thus  formed  within  the  field  of  the  conscious 
personality. 

If  now  we  approach  the  treatment  of  these  psychas- 
thenic  obsessions  we  have  at  our  disposal  a  variety  of  methods 
ranging  from  simple  explanation  and  persuasion  on  one  side 
to  hypnoidization  and  hypnosis  upon  the  other.  In  order 
to  render  our  discussion  of  these  therapeutic  measures  as 
concrete  as  possible,  I  shall  give  a  brief  report  of  some  cases 
actually  treated,  together  with  an  account  of  what  was  done 
in  each  individual  case. 

Case  I.  Mrs.  M.,  aged  thirty-five,  came  into  the  hospi- 
tal upon  the  advice  of  her  physician,  complaining  of  a  peculiar 
constantly  repeated  and  involuntary  hacking,  which  sounded 
as  though  she  were  trying  to  clear  her  throat.  Her  move- 


Conditions  in  Psychasthenia  151 

ments  involved  the  muscles  of  the  larynx,  those  of  the  neck 
and  thorax,  together  with  the  diaphragm;  in  a  word  they  had 
the  characteristics  of  a  respiratory  tic.  Drugs,  local  applica- 
tions to  the  throat,  and  electricity  had  been  tried  at  intervals 
during  more  than  four  years  without  avail.  Asked  regarding 
the  origin  of  her  nervous  trouble,  the  patient  could  give  no 
information  except  the  fact  that  she  could  not  voluntarily 
control  the  hacking.  She  was  then  placed  in  the  hypnoidal 
state  as  described  by  Dr.  Sidis,  when  the  following  history 
was  obtained :  Five  years  ago  while  employed  as  an  operative 
in  a  mill  she  suffered  from  a  sore  throat  which  lasted  for  three 
days,  at  the  end  of  which  time  she  consulted  a  physician,  who 
told  her  that  she  had  tonsilitis  and  informed  her  that  it  would 
be  necessary  to  burn  out  her  tonsils.  She  was  much  fright- 
ened by  this  information  and  for  several  days  thereafter  felt 
herself  quite  disturbed.  Her  tonsillar  symptoms  soon  dis- 
appeared and  she  returned  to  work.  Three  weeks  later, 
however,  she  was  attacked  for  the  second  time  and  again 
consulted  another  physician  who  told  her  that  her  tonsils 
were  diseased  and  advised  her  to  have  them  cut  out.  The 
fear  of  cutting  added  to  her  previous  fear,  now  revived,  of 
burning  her  tonsils,  threw  her  into  such  a  nervous  state  that 
she  was  able  to  think  of  nothing  else.  At  this  time  she 
noticed  a  disagreeable,  stinging,  tickling  feeling  in  her  throat, 
which  she  tried  to  remove  by  hacking,  but  without  success. 
As  the  tickling  remained,  her  hacking  became  more  and 
more  frequent  and  at  the  time  she  came  under  observation 
had  taken  on  the  character  of  a  tic;  for  she  said  she  felt  an 
uncontrollable  impulse  to  hack  although  she  confessed  there 
was  little  if  any  abnormal  feeling  in  her  throat.  Here,  then, 
was  an  obsessive  complex  discharging  itself  through  motor 
pathways  as  a  tic  and  having  its  origin  in  the  experiences  we 
have  described.  At  the  time  of  my  examination  she  admitted 
that  the  fear  of  a  possible  future  cutting  or  burning  of  her 
tonsils  still  possessed  her.  While  in  the  hypnoidal  state 


152  Psychotherapeutics 

she  was  encouraged  and  helped  to  recall  the  complete  ex- 
perience in  as  great  detail  as  possible.  She  was  then  told 
with  much  emphasis  that  her  tonsils  were  perfectly  healthy, 
that  no  cutting  or  burning  ever  was  or  ever  would  be  re- 
quired; that  the  tickling  sensation  in  her  throat  arose  from 
the  constant  fixation  of  attention  upon  this  part;  that  she 
would  feel  no  more  desire  to  hack  because  her  supposed 
reason  for  hacking  had  ceased  to  exist,  and  finally,  that 
when  she  should  open  her  eyes  she  would  feel  better  than 
she  had  in  a  great  many  years.  Much  emphasis  was  placed 
upon  this  feeling  of  health  because  it  was  desired  to  leave 
her  on  the  crest  of  a  pleasurable  emotion,  which  of  itself  has 
a  very  great  suggestive  value.  What  had  been  predicted 
in  her  regard  actually  occurred.  When  she  sat  up,  her  tic 
had  disappeared,  and  she  expressed  herself  as  feeling  quite 
grateful  and  happy.  The  seance  of  hypnoidization  lasted 
an  hour,  and  except  for  two  slight  recurrences  easily  removed 
by  waking  suggestion,  this  patient  has  had  no  further 
difficulty. 

Case  II.  A  young  married  woman  came  under  obser- 
vation complaining  of  a  very  distressing  type  of  obsession, — 
namely,  the  fear  of  losing  control  of  her  bladder.  For  nine 
years,  with  an  interval  of  some  six  months,  during  which  she 
was  comparatively  free,  this  imperative  fear  had  dominated 
her  mind,  so  that  her  life  had  been  ordered  with  regard  to 
the  demands  of  her  obsession.  Not  only  did  she  have  the 
mental  fear,  but  also  a  distressing  sensation  in  the  bladder 
whenever  her  obsession  was  active.  It  is  scarcely  possible 
to  describe  the  suffering  which  she  had  endured.  She  could 
not  engage  in  the  social  functions  which  she  enjoyed  for  fear 
of  a  humiliating  accident.  The  theater  was  closed  to  her; 
she  could  not  ride  for  any  distance  upon  cars,  nor  accept 
invitations  to  visit  any  one  save  friends  in  whose  houses  she 
felt  at  ease.  In  her  own  home  she  experienced  rather  a 
different  feeling, —  not  the  fear  of  incontinence,  which  did 


Conditions  in  Psychasthenia  153 

not  often  occur,  but  the  depressing  idea  that  her  life  was  to  be 
circumscribed  by  a  malady  over  which  she  had  no  control. 
On  the  theory  that  her  trouble  was  due  to  cystitis,  her  bladder 
had  been  washed  out  with  various  solutions,  among  them 
boric  acid  and  nitrate  of  silver,  and  she  had  swallowed  a 
host  of  drugs  like  citrate  of  potassium,  buchu,  and  oil  of 
sandalwood.  From  a  careful  consideration  of  her  history  it 
seemed  reasonable  to  suppose  her  that  bladder  sensations 
were  secondary  to  her  obsession,  rather  than  that  her  obses- 
sion was  consequent  upon  a  real  cystitis.  An  examination 
of  her  urine,  which  contained  nothing  abnormal,  confirmed 
this  view.  Upon  the  principle  that  every  obsession  has  a 
history,  if  only  we  can  discover  it,  an  attempt  was  made  to 
determine  the  origin  of  this  one.  No  special  devices  were 
employed  other  than  a  precise  reconstruction  of  the  clinical 
history.  It  then  appeared  that  some  nine  years  ago,  a  few 
days  after  the  birth  of  her  first  child,  she  was  troubled  while 
in  bed  with  a  slight  degree  of  cystitis  and  as  a  fact  did  lose 
control  of  her  bladder.  This  made  her,  as  she  says,  rather 
ashamed  of  herself,  and  struck  her  as  being  an  unfortunate 
occurrence.  Some  few  weeks  later,  while  out  walking,  she 
suddenly  felt  a  curious  burning  sensation  in  her  bladder. 
Immediately  she  was  seized  with  the  fear  that  there  was  to 
be  another  loss  of  control;  this,  however,  did  not  happen. 
Nevertheless  the  fear  continued,  and  has  persisted  to  within 
a  very  recent  period.  Here,  then,  was  an  obsession  of  dis- 
agreeable type,  which  had  arisen  upon  the  basis  of  a  previous 
experience.  The  memory  of  an  actual  loss  of  bladder  con- 
trol plus  a  certain  sensation  referred  to  the  bladder  had 
become  associated  in  a  complex  which  functioned  as  an 
obsessive  fear  of  incontinence.  While  the  patient  could 
recall  perfectly  her  experiences  as  given  above,  she  had  no 
idea  that  they  had  anything  to  do  with  her  present  fear  until 
this  was  pointed  out  to  her,  whereupon  she  acquiesced 
readily  in  this  explanation.  Before  her  treatment  had 


154  Psychotherapeutics 

progressed  further  than  the  second  consultation,  an  oppor- 
tunity presented  itself  of  testing  the  truth  of  our  hypothesis, 
namely,  that  her  bladder  symptoms  were  the  tail  to  a  mental 
kite.  On  this  special  occasion  she  was  compelled  to  wait 
some  little  time,  and  when  I  began  to  talk  to  her  it  was  very 
evident  that  her  obsession  was  in  full  swing.  An  attempt 
was  made  then  and  there  to  disrupt  her  obsessive  complex  by 
forcibly  replacing  for  the  association  represented  by  "  bladder 
loss  of  control,"  another  association,  "  bladder  full  control." 
This  was  accomplished  by  stating  and  restating  very  posi- 
tively and  in  detail  that  she  could  certainly  control  her 
bladder,  as  the  event  would  surely  prove.  For  about  twenty 
minutes  her  emotional  agitation  was  intense,  but  finally 
subsided  with  the  result  that  although  she  was  anything  but 
calm,  her  faith  in  her  obsession  had  been  somewhat  di- 
minished. By  dint  of  subsequent  and  repeated  persuasion 
her  fear  was  finally  removed,  so  that  unltimately  at  the  end 
of  eight  months  she  entered  upon  her  social  pleasures  and 
duties  with  normal  satisfaction.  Untiring  persuasion  in 
the  face  of  obstacles  had  succeeded  in  disrupting  an  obsessive 
complex  which  for  nine  years  had  proved  rebellious  to  all 
other  medical  treatment. 

Case  III.  A  man,  aged  32,  presented  a  very  interest- 
ing obsession,  which  was  this:  he  could  not  get  upon 
a  street  car  whose  number  was  odd.  Cars  with  even  num- 
bers gave  him  no  trouble,  but  if  an  odd  numbered  car  came 
along  he  was  compelled  to  let  it  pass  no  matter  what  his 
hurry  might  be.  He  could  recall  nothing  which  would  shed 
light  upon  this  curious  obsession,  but  when  placed  in 
hypnosis  he  gave  the  following  story:  When  about  eighteen 
years  old  he  was  one  day  walking  upon  the  street  when  he 
witnessed  a  street  car  strike  and  injure  a  child  who  unex- 
pectedly ran  out  from  behind  a  wagon.  The  sight  of  this 
accident  gave  him  a  very  marked  emotional  shock,  which 
upset  him  for  several  days  thereafter.  Standing  near  the 


Conditions  in  Psychasthenia  155 

scene  of  the  accident  he  noticed  that  the  car  bore  the  number 
213,  and  thought  to  himself,  "  Well,  there  is  always  ill-luck 
in  13."  Ever  since  the  time  of  this  experience  he  has  had 
his  strange  aversion  to  riding  upon  cars  bearing  odd  numbers, 
although  his  waking  self  could  give  no  account  of  or  even 
conjecture  regarding  the  derivation  of  his  obsession.  During 
hypnosis  it  was  suggested  to  him  that  the  child  whose  acci- 
dent he  witnessed  was  not  really  injured  and  had  recovered 
completely.  Furthermore,  he  was  told  that  odd  numbers 
were  quite  the  same  as  even  numbers;  that  they  would  no 
longer  cause  him  any  trouble,  and  in  fact  would  give  him  no 
concern  whatever;  and  finally  that  like  all  other  normal 
persons  he  would  pay  no  attention  to  the  number  of  the  car 
he  desired  to  ride  upon.  These  hypnotic  treatments  were 
continued  daily  for  eight  days  and  resulted  in  the  complete 
removal  of  the  obsession,  which,  so  far  as  I  know,  has  not 
returned. 

Case  IV.  A  young  woman,  by  occupation  a  stenog- 
rapher, complained  of  an  obsession  which  took  the  form 
of  a  more  or  less  troublesome  fear  of  insanity.  She  was 
conscious  that  her  intellectual  activity  was  practically  normal, 
because  she  was  engaged  daily  in  an  exacting  profession, 
which  she  carried  out  with  complete  success.  This  fear, 
however,  of  insanity,  while  not  painfully  imperative,  was 
nevertheless  present  on  occasion  as  a  disturbing  under- 
current in  her  mind.  She  did  not  appreciate  the  origin  of 
her  fear  until  it  was  disclosed  to  her  as  follows:  About  two 
years  previously,  while  sitting  in  her  room  one  night,  she  was 
locked  in  by  another  woman  in  the  house  who  had  become 
unbalanced  in  mind.  Being  unable  to  release  herself  from 
her  confinement,  on  account  of  the  door  having  been  locked 
from  the  outside,  she  spent  something  over  an  hour  in  dread 
of  what  might  happen  to  her  should  the  woman  return  and 
attempt  to  enter  the  room.  As  a  matter  of  fact,  nothing  of 
this^sort  occurred,  for  she  was  released  from  her  confinement 
by  another^dweller  in  the  same  house.  Naturally,  she  was 


156  Psychotherapeutics 

very  much  upset,  and  from  that  time  until  she  came  under 
observation  suffered  from  this  disquieting  fear  of  insanity. 
It  was  not  difficult  to  trace  the  origin  of  the  obsessive  com- 
plex. Psychologically,  it  was  merely  the  persistence  in  her 
mind  of  the  memory  of  her  former  experience,  bereft  of  its 
characteristics  as  a  memory.  There  had  thus  arisen  an 
obsessive  complex  which  functioned  automatically  and 
appeared  in  consciousness  as  a  present  fear  of  mental  disease. 
By  means  of  persuasion  and  explanation,  the  whole  matter 
was  explained  to  her,  and  in  the  course  of  about  four  weeks 
she  found  her  fear  gradually  fading  until  eventually  she  had 
substituted  a  complete  understanding  of  the  situation  for  her 
obsession,  and  this  brought  about  its  ultimate  removal. 

In  the  cases  just  described,  one  may  observe  the  success- 
ful results  that  sometimes  follow  the  use  of  hynosis,  hypnoi- 
dization,  and  persuasion,  in  the  treatment  of  psychasthenic 
obsessions.  I  would  not,  however,  wish  to  convey  the  im- 
pression that  every  case  which  clinically  manifests  itself  by 
psychasthenic  symptoms  is  treated  with  equally  great  success. 
Some  of  them  are  extremely  obscure  as  to  their  genesis, 
and  equally  difficult  in  the  way  of  successful  treatment.  In 
conclusion,  I  wish  to  describe  such  a  case,  which  was  char- 
acterized by  obsessions,  feelings  of  unreality,  incompleteness, 
and  strangeness,  and  to  some  extent  by  depersonalization. 

Case  V.  Mr.  X.,  by  occupation  a  postman,  complained 
that  from  the  time  he  was  about  seventeen  years  of  age  he 
had  been  afflicted  with  feelings  of  incompleteness,  by  obses- 
sions of  fear  of  insanity,  and  by  the  lack  of  emotional  reaction 
to  his  environment,  whether  pleasurable  or  painful.  Through- 
out his  life,  as  long  as  he  could  remember,  he  had  always  been 
reticent,  and  as  a  boy  found  it  difficult  to  associate  with  his 
playmates  because  of  shyness.  On  one  occasion,  when  at 
school,  he  attempted  to  give  a  recitation,  but  failed  through 
an  acute  attack  of  stage  fright.  He  got  along  tolerably  well 
until  he  was  seventeen,  when  he  suffered  an  attack  of  typhoid 
fever,  at  which  time  the  more  troublesome  symptoms  of 


Conditions  in  Psychasthenia  157 

which  he  complains  began.  He  says  that  he  seems  to  lack 
the  ability  to  feel  pleasure  or  pain  in  what  he  does.  At  the 
theater,  for  example,  he  experiences  no  emotion,  but  sits 
there,  as  he  says,  "  equally  indifferent  to  whatever  may  be 
going  on."  He  sees  the  play  and  hears  the  actors,  but 
cannot  get  in  tune  with  them.  In  his  daily  work  of  delivering 
letters  he  finds  no  pleasure,  except  that  it  serves  him  as  a 
means  of  occupation  and  a  source  of  livelihood.  Con- 
stantly throughout  the  day,  more  particularly  when  he  is 
unoccupied,  the  thought  flashes  into  his  mind  that  he  is 
going  to  become  insane,  or  that  his  malady  will  terminate 
in  complete  despair.  He  used  to  enjoy  the  reading  of  poetry, 
but  complains  that  now  poems  are  to  him  merely  so  many 
words,  and  that  while  he  understands  what  the  poet  is  trying 
to  convey,  he  derives  no  answering  emotion  from  his  reading. 
He  states  his  feelings  thus :  "  I  seem  to  myself  to  be  another 
person.  It  appears  to  me  that  there  is  a  split  between  my 
emotional  and  my  intellectual  nature.  I  cannot  get  in  tune 
with  things,  and  the  greatest  good  fortune  or  the  greatest 
misfortune  in  the  world  would  leave  me,  I  believe,  equally 
unaffected." 

Throughout  several  months  the  attempt  has  been  made 
by  psycho-analysis  to  uncover  some  source  for  the  psych- 
asthenic  symptoms  presented,  but  without  success.  His 
seems  to  be  one  of  those  cases  wherein  the  psychasthenic 
feelings  of  incompleteness,  insufficiency,  and  strangeness, 
together  with  obsessions,  are  so  interwoven  with  the  texture 
of  the  mind  as  to  render  their  complete  removal  practically 
impossible.  No  matter  what  he  attempts  to  do,  there  is  a 
fundamental  perversion  of  feeling  and  emotion,  and  so  long 
as  this  is  present,  his  obsessions  of  anxiety  and  despair  arise 
and  continue.  By  persuasion  and  frequent  practice  he  has 
been  enabled  so  to  switch  his  obsessions  into  a  corner  of  his 
mind  as  to  enable  him  to  pursue  his  daily  work  with  a 
certain  external  and  mechanical  success.  This,  however, 


158  Psychotherapeutics 

requires  a  constant  effort  on  his  part,  because  there  is  alwaye 
a  tendency  for  his  psychasthenic  symptoms  to  obtruds 
themselves.  Hypnoidization  and  hypnosis  have  been  of 
some  value  in  the  sense  that  after  a  treatment  he  experiences 
a  certain  relief  for  a  time,  but  this  never  lasts  more  than  two 
or  three  days,  at  the  most.  His  treatment  has  extended 
over  the  greater  part  of  a  year,  but  it  must  be  said  that  the 
psychasthenic  substrate  of  mind  continues  virtually  un- 
changed. 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD 

BY  TOM  A.  WILLIAMS,  M.B.,  C.M.   (EDIN.) 
Washington,  D.  C. 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD 

DEFINITION.     Just  as  psychotherapy  denotes  not 
treatment  of  the  mind,  but  treatment  by  psychic 
means  (i),  so  I  shall  use  the  word  psychoprophy- 
laxis,  not  to  signify  the  prevention  of  psychic  dis- 
orders, but  to  mean  the  preservation  of  health  by  psychic 
means. 

The  exigencies  of  time,  however,  will  on  this  occasion 
restrict  the  consideration  of  the  subject  to  the  psychic  means 
to  be  employed  for  the  restriction  of  psychic  disorders, 
leaving  aside  the  fascinating  psychoprophylactic  procedures, 
which  are  one  of  the  main  elements  used  by  the  physician 
to  persuade  patients  whose  symptoms  have  been  long 
absent,  to  regulate  their  life  so  as,  for  instance,  to  prevent 
failure  of  cardiac  compensation  and  asystole,  or  to  continue 
a  mercurial  course;  or,  again,  in  order  to  cure  an  incipient 
tuberculosis,  to  persuade  them  to  continue  to  visit  him,  to 
avoid  foul  air,  take  regular  meals,  and  avoid  excesses  of 
work  and  pleasure.  Still  more  largely  is  psychoprophy- 
laxis  employed  by  the  sanatarian,  who  persuades  first  his 
colleagues,  later  public  opinion,  and  lastly  legislatures 
and  municipalities  to  adopt  the  means  for  the  prevention  of 
disease.  For  instance,  the  greatest  obstacle  to  the  employ- 
ment of  efficient  means  to  combat  yellow  fever  lay  in  the 
psychological  attitude  of  the  people  of  the  South.  Their 
horror  of  "  yellow  jack  "  was  so  great  that  they  could  not 
even  discuss  the  subject.  It  was  only  when  some  hope  was 
inspired  that  the  dreaded  disease  might  be  prevented  that 
the  phobia  could  be  controlled  sufficiently  to  permit  of  action. 
In  short,  the  means  of  overcoming  public  and  personal 
apathy  and  mental  inertia  are  the  most  difficult  problems  of 
preventive  medicine.  Were  this  done,  the  tuberculosis 
dispensary  would  really  perform  the  functions  it  is  supposed 
to  perform,  and  which  I  am  assured  it  does  not  do  from  a  lack 

161 


1 62  Psychotherapeutics 

of  this  psychic  motive  power  of  persuasion.  The  disgraceful 
typhoid  situation  in  Pennsylvania  will  terminate  only  when 
the  people's  feelings  are  aroused  by  conviction  to  the  pitch 
of  real  will  that  the  abuse  shall  cease. 

Only  those  ignorant  of  psychology,  and  especially 
laymen,  and  more  particularly  ecclesiastics,  who  are  always 
dualists,  will  expect  too  much  from  psychoprophylaxis. 
The  physician  is  not  likely  to  forget  the  state  of  physical 
nerve  insufficiency  (10),  which  is  at  the  root  of  so  many 
psychic  perturbations,  which  are  often  mere  exaggerations 
of  the  tendencies  of  the  character,  normal  and  morbid;  nor 
will  the  physician  forget  the  role  of  intoxication  in  inducing 
mental  confusion,  melancholy,  acute  psychasthenic  symp- 
toms, twilight  states,  often  miscalled  hysterical.  The 
physician  will  take  care  that  the  exhortation,  advice,  and 
instruction  he  brings  to  bear  are  not  obstructed  by  the  intel- 
lectual handicap  of  exhausted  or  intoxicated  neurones  (n), 
nor  by  the  affective  distress  caused  by  insufficient  oxidation, 
intestinal  irritation,  and  so  on. 

In  other  words,  he  will  adopt  a  monistic  interpretation 
of  his  patient,  contrary  to  the  view  of  Dejerine  (12),  who  has 
said  that  to  be  a  good  psychotherapeutist  one  must  not  be 
a  determinist.  He  has  not  taken  into  consideration  the  fact 
that  the  therapeutist  himself,  in  becoming  part  of  the  pa- 
tient's environment,  determines  a  new  sequence  of  ideas. 
On  the  contrary,  as  monists  we  shall  protect  our  patient  from 
such  dualistic  vagaries  as  Christian  Science,  for  with  the 
monistic  attitude  we  are  much  more  apt  to  constantly  relate 
mind  and  brain  to  one  another. 

But  one  must  be  careful  to  avoid  the  pitfall  into  which 
many  psychiatrists  at  one  time  fell,  but  which  we  now  know 
how  to  avoid,  thanks  to  the  efforts  of  the  French  school  and 
of  men  like  Adolph  Meyer  and  Morton  Prince  in  America. 
I  refer  to  the  premature  attempt  to  refer  every  psychic  per- 
turbation to  a  vice  of  structure,  as,  for  example,  is  done  by 


Psychoprophylaxis  in  Childhood  163 

Swift  (13)  when  he  relates  the  difference  of  mental  capacity 
between  the  adult  and  a  child  of  seven  to  corresponding 
neural  changes.  As  a  matter  of  fact,  such  difference  is  one 
merely  of  orderliness  of  mental  reactions,  as  is  shown  by  the 
superiority  of  the  child  in  acquiring  unrelated  facts,  as,  for 
instance,  words  and  the  use  of  language.  A  man  deprived 
of  education  would  show  no  greater  capacity  and  have 
perhaps  less  potentiality  than  a  child  of  seven.  Of  course, 
ultimately,  any  acquired  skill  must  depend  upon  neuronic 
dispositions  of  molecular  kind;  but  we  are  not  even  in  a 
position  to  perceive  the  nature  of  these,  though  that  they 
depend  upon  the  functional  capacity  of  the  neurones  is 
evident  from  the  disappearance  of  skill  and  other  forms  of 
memory  during  intoxication,  as  well  as  after  destruction 
of  nerve  matter. 

Thus,  as  of  all  prophylaxis,  an  essential  preliminary  is 
diagnosis,  by  which  only  an  intelligent  prophylaxis  can  be 
guided. 

The  essence  of  psychoprophylaxis,  as  of  psychotherapy 
and  education,  is  to  associate  useful  activities  with  agreeable 
feeling-tones,  and  to  disassociate  from  useless  or  injurious 
acts  the  agreeable  feeling-tones  that  may  have  been  acquired. 
For  instance,  the  kind  of  social  obsession  which  eventuated 
in  the  crusades  does  not  differ  psychologically  from  that 
which  leads  to  empire  building;  but  the  former  was  a  per- 
nicious activity,  while  the  latter  may  have  its  uses.  A  fixed 
idea  may  often  prove  an  incentive  to  useful  work  in  individ- 
uals as  well  as  in  societies. 

Fundamentally  none  of  the  processes  we  employ  differs 
from  those  used  by  Pawlow  (2)  in  "  conditioning  "  the  re- 
flexes of  his  experimental  dogs,  when  he  caused  an  expectant 
wagging  of  the  tail  and  a  flow  of  saliva  and  gastric  juice  upon 
ringing  a  bell. 

Similarly,  when  the  petted  child  ceases  his  crying  upon 
seeing  his  father,  it  is  because  he  reflexly  has  associated  a 


164  Psychothfrapeutics 

greater  discomfort  with  the  persistency  of  his  tears  than  with 
their  cessation.  The  affect,  fear,  aroused  by  association, 
banishes  that  of  fretfulness. 

Gradually  the  emotional  element  of  the  reflex  fades  (3), 
and  sight-of-father  connotes  cessation-of-weeping.  This 
leads  to  a  respect-reflex.  On  the  contrary,  the  intellectual 
content  of  the  phenomenon  may  be  submerged  below  the 
threshold  of  consciousness,  only  the  aifect  persisting;  in 
which  case  occur  painful  or  pleasurable  emotions,  the  origin 
of  which  is  not  manifest  in  the  subject.  Recollect  that 
functional  derangement  may  continue  just  because  it  began. 

The  interest  sentiment  is  an  essential  of  all  psycho- 
therapy, as  of  effective  pedagogy;  as  when  a  young  child 
about  to  cry  is  quickly  diverted  to  a  passing  scene  or  made 
to  perform  an  act.  The  doing  so  quickly  substitutes  the  new 
interest  sentiment  for  the  disagreeable  former  one,  the  feel- 
ings are  changed,  and  we  have  performed  psychotherapy 
by  distraction  and  substitution. 

This  simple  principle,  then,  of  finding  or  creating  the 
interest-affect,  associating  it  with  the  desired  conduct,  and 
training  it  into  habit,  as  simply  illustrated  above,  may  be 
found  at  the  bottom  of  even  the  complicated  ratiocinations 
required  in  the  therapy  of  the  psychasthenic,  and  is  also  the 
outstanding  indication  in  all  paranoid  psychoses. 

On  the  other  hand,  in  the  hysteric,  if  the  tour  de  force 
cannot  be  employed  or  fails,  the  method  of  repetition  is 
requisite.  Those  who  do  not  depend  upon  reason  must 
grow  into  feeling  by  accustomedness,  if  the  first  blow  fails. 
Who  does  not  know  of  communities  where  a  doctor's  prestige 
is  measured  by  the  years  he  has  spent  there,  of  the  reverence 
derived  from  seniority  ?  The  mentality  which  accedes  to 
such  a  criterion  is,  of  course,  irrational,  and  it  is  at  bottom 
that  of  the  hysteric.  Hence,  the  clinical  procedure  of  isola- 
tion to  increase  the  speed  of  accustomedness,  and  of  reitera- 
tion to  force  into  the  unreasoning  affectivity  a  realization  of 


Psychoprophylaxis  in  Childhood  165 

the  notions  to  which  the  patient  is  refractory.  This  is  not 
persuasion :  it  is  the  method  of  pertinacity. 

Hypnosis,  hypnoidization,  etc.,  are  merely  means  of 
increasing  impressionability  to  suggestions.  In  principle 
there  is  no  difference  between  these  and  such  means  as  were 
empirically  used  in  ancient  times  through  ceremonies,  re- 
ligious observances,  ritual,  etc.,  for  the  same  purpose.  (Such 
methods  can  perform  nothing  more  wonderful  than  Judge 
Lindsay's  feat  of  persuading  the  incorrigible  truant  boy  to 
himself  purchase  a  ticket  and  travel  many  hours  to  a  reform 
school.) 

As  set  forth  elsewhere,  the  distinction  between  sugges- 
tion and  persuasion  is  one  of  awareness  by  the  percipient  (4), 
the  acceptee.  Hence,  to  be  unaware  of  why  one  accepts 
an  opinion  that  so  and  so  is  the  most  skillful,  and  to  do  so  on 
length  of  acquaintance  is  to  do  so  by  suggestion;  and  an  idea 
received  by  suggestion  is  a  hysterical  one,  as  shown  by 
Babinski  in  his  definition,  "A  hysterical  symptom  is  one 
susceptible  of  induction  by  suggestion  and  of  removal  by 
suggestion  —  persuasion.  (5)  ") 

In  all  of  these  procedures  the  preliminary  sentiment  of 
respect,  reverence,  awe,  is  engendered  among  the  people  by 
the  devices  of  expectation,  unfamiliarity,  and  sacredness  or 
mystery.  This  sentiment  in  modern  democratic  days  is  less 
the  actuating  factor  than  that  of  the  pseudo-intellectual 
shibboleth,  which  seems  to  be  a  strongly  determining  factor 
in  the  popularity  of  modern  movements  of  all  kinds.  The 
social  tropisms  of  the  unthinking  may  be  graded  in  three 
categories  of  decreasing  strength,  beginning  in  ritual  and 
passing  via  shibboleth  to  snobbery,  its  modern  attenuated 
form.  In  all  these  modes  of  conveying  influence,  distraction 
is  obtained  by  engaging  the  sight  by  the  rhythm  of  the  cere- 
mony and  by  engaging  the  hearing  by  the  rhythm  of  music, 
to  which  are  often  added  the  dynamic  rhythms  of  movements 
directed  conformably  with  the  desires  of  the  priest  or  other 
operator. 


1 66  Psychotherapeutics 

The  distraction  thereby  obtained,  almost  tantamount 
in  some  cases  to  a  dreamy  state,  favors  what  we  nowadays 
variously  call  passivity,  psychological  automatism,  mental 
dissociation,  suggestibility. 

In  this  state,  plasticity  of  the  desires  is  much  facilitated, 
the  operations  of  the  will  are  in  abeyance;  for  the  critical 
judgment  of  the  intelligence  is  no  longer  in  action.  The 
subject  does  not  attain  to  the  phantasmagoria  of  the  complete 
dream  state;  for  susceptibility  to  extraneous  stimuli  is  much 
stronger  than  in  sleep,  or  even  than  in  somnambulism. 
The  state  resembles  that  in  the  day-dream,  in  which,  how- 
ever, the  meditations  are  less  systematically  determined. 

The  moral  control,  the  psychoprophylaxis,  secured  by 
these  means  has  in  the  past  been  incalculable;  but  as  the 
sanction  of  these  procedures  has  been  crumbled  by  the 
trenchancy  of  modern  analysis,  and  we  now  live  in  a  scientific 
age,  it  is  necessary  to  employ  psychoprophylactic  means 
which  accord  with  the  intellectual  development  of  civilized 
man.  Thus  the  further  we  depart  from  the  methods  of 
mental  distraction,  mystical  appeal,  and  pseudo-scientific 
shibboleths  (6),  the  more  soundly  and  permanently  shall  we 
succeed  in  preventing  the  vagaries  of  the  neurotic,  and  the 
less  shall  we  be  a  party  to  the  justification  of  the  occult 
manner  in  which  many  of  the  public,  and  even  some  doctors 
conceive  such  psychological  interpretations  as  hypnosis,  sub- 
consciousness,  divided  personality,  subliminal  phenomena, 
mental  dissociation,  etc.  I  he  more  we  appeal  to  the  method 
of  common  sense,  plain  matter  of  fact  every  day  conduct 
(which  is  obviously  the  method  so  clearly  explained  and 
outlined  by  Dr.  Taylor)  (7),  the  less  chance  shall  we  give  for 
the  delusional  interpretations  of  clairvoyants,  medium 
spiritualists,  and  others  whose  sentiment  of  psychic  imper- 
fection leads  them  to  seek  in  the  occult  the  satisfaction  they 
cannot  find  in  current  explanations  of  their  mental  life. 

It  is  to  be  hoped  that  our  labors  along  with  other  sym- 


Psychoprophylaxis  in  Childhood  167 

posia  like  this  may  eventuate  in  a  working  doctrine  held  in 
common  by  the  whole  medical  profession,  which  will  enable 
us  to  forestall  and  prevent  the  development  of  misinformation 
concerning  psychic  states  which  have  been  responsible  for 
the  birth  and  evolution  of  such  modern  movements  as 
Christian  Science,  Emmanuelism,  neo-yogiism,  and  other 
harmful  misapplications  of  psychotherapeutics. 

A  concrete  illustration  of  what  psychoprophylaxis  can 
do  is  afforded  by  a  recent  communication  of  G.  Guidi  (8), 
who  has  shown  that  fifteen  per  cent  of  attacks  of  migrain  are 
preceded  even  for  days  by  psychic  symptoms  either  of  ex- 
citable or  depressant  type,  e.g.,  the  need  to  move  about,  to 
talk,  tell  funny  or  obscene  stories,  to  look  out  for  ridiculous 
situations,  to  laugh  at  them,  or  by  a  desire  to  go  alone,  irrita- 
bility, sadness,  anxiety,  even  tears.  I  have  myself  noticed 
a  feeling  of  unusual  mental  clarity,  of  power,  in  certain  cases. 
(Every  one's  disposition  is  modified  (9)  by  exercise,  oxygen, 
food,  etc.;  we  all  have  defective  times.  Want  of  exercise  and 
elimination  leaves  toxins  which  cause  restlessness,  irrita- 
bility and  prevent  quiet  intellectual  work.)  Now  if  the 
migrainous  attack  can  be  prevented  as  a  result  of  diagnosing 
this  modified  psychic  state,  it  is  evident  that  by  prescribing 
mental  and  physical,  including  digestive,  rest,  we  shall  have 
performed  psychoprophylaxis. 

We  must  recollect  that  during  the  period  while  the 
functions  of  the  neurones  are  perverted  by  physical  maladies, 
especially  the  intoxicative  ones  which  we  call  fevers,  bad 
habits  of  action  may  be  initiated  and  be  reinforced  through 
convalescence  and  become  characteristics  of  the  individual. 
As  a  matter  of  fact  more  careful  psychic  discipline  is  needed 
while  neuronic  activity  is  perverted  (14)  than  when  it  is 
healthy,  and  it  is  the  family  physician's  task  to  guide  the 
psychic  management  of  his  patients  as  well  as  the  physical. 

1  he  principle  of  mental  prepossession  and  inertia  shows 
the  power  of  an  idea,  which  may  originate  as  the  result  of 


1 68  Psychotherapeutics 

slight  physical  disorder.  Binet  (15)  has  illustrated  this 
experimentally  by  showing  how  children  will  go  on  increasing 
the  length  of  a  line  when  drawing  from  memory  a  series  of 
lines  shown  them,  though  only  the  first  few  of  them  were 
actually  increased.  Another  example  (16)  is  the  remarkable 
experience  of  the  enumerators  of  the  last  census  in  endeavor- 
ing to  adapt  themselves  to  the  supposed  difficulties  of  a  new 
dactylograph.  Their  work  was  rendered  so  disappointing 
by  the  "  pressing  "  under  difficulties  that  new  clerks  had  to 
be  employed:  these  quickly  surpassed  their  more  experi- 
enced colleagues.  To  be  "  on  edge  "  is  not  the  best  state 
for  showing  high  skill:  as  every  golfer  knows,  it  connotes 
divided  attention. 

The  state  of  keyed-up  prepossessedness  is  induced  by 
an  excessive  interference  (19)  with  the  activities  of  the  child; 
when  every  act  has  been  regulated  and  controlled,  he  will 
constantly  be  referring  for  approval  instead  of  confining 
himself  to  the  task  in  hand.  This  principle  may  be  illus- 
trated by  the  boy  who  instead  of  looking  at  a  ball  he  is  ex- 
pected to  catch  looks  at  the  thrower  for  the  approval  or 
blame  he  anticipates.  Overconscientiousness  is  quickly 
developed  by  such  procedure;  but,  again,  psycho-diagnosis 
will  eliminate  the  danger,  for  it  would  be  a  mistake,  for 
fear  of  risking  over-conscientiousness,  to  have  upset  the 
entire  sense  of  fitness  of  a  boy  of  three  who  came  to  his 
father  to  be  thrashed,  declaring  he  had  thrown  a  knife  at  the 
cook,  an  act  which  had  been  specifically  forbidden. 

The  source  of  another  danger  proceeding  from  over- 
conscientiousness  is  that  of  shame  of  eating  (18),  as  illustrated 
by  the  same  boy,  when  conscious  of  wrongdoing,  repeating 
"no  bananas  for  boy"  (a  dish  he  loves).  But  it  is  very 
easy  to  prevent  a  perverted  affect  in  this  case,  while  at  the 
same  time  furnishing  a  consistent  and  coherent  system  of 
conduct  and  morality. 

In  this  connection  one  must  avoid  formation  of  bad 


Psychoprophylaxis  in  Childhood  169 

affective  habits  during  the  temporary  intoxication  of  poor 
oxydation  due  to  a  full  stomach  or  too  heavy  a  meal.  In 
this  state  a  child  while  playing  hard  may  be  carried  away  by 
excitement  till  he  loses  his  temper  and  begins  to  cry,  just 
because  "  things  are  too  much  for  him." 

Again,  constantly  interrupting  him  in  a  train  of  thought 
by  regulating  his  least  little  impulse  promotes  suggestibility, 
and  the  child  becomes  accustomed  not  to  act  until  told.  In 
not  availing  one's  self  of  a  moment  of  excitement  to  inculcate 
a  difficult  act,  one  loses  a  chance  of  cultivating  presence  of 
mind,  even  during  emotional  states.  This  may  even  be 
done  during  pain  and  tears  by  making  the  child  do  some- 
thing else  during  them,  thus  gaining  self-control.  In  speak- 
ing slightingly  of  what  one  wishes  contemned,  be  sure  it  is 
not  against  human  nature.  To  forbid  healthy  acts  to  a  boy 
is  detrimental  to  him,  he  derives  a  false  notion  of  morals 
when  he  knows  that  innocent  acts  are  forbidden.  So  pro- 
vide ample  outlet  for  spirit  of  adventure,  without  which  a 
boy's  whole  character  suffers.  It  either  is  exercised  illicitly, 
or  is  suppressed  and  forms  intellectual  dishonesty  and  emo- 
tional incompleteness,  so  fertile  a  source  of  psychasthenia. 

But  in  early  childhood,  and  in  some  matters  even  in 
adolescence,  it  is  best  to  employ  authoritative  affirmation 
rather  than  suggestion.  A  child  cannot  see  the  reasons  for 
the  need  for  certain  prohibitions;  and  it  is  a  bad  principle 
to  be  constantly  side-stepping  issues  by  the  giving  of  sug- 
gestions. Besides,  it  prevents  the  child  acquiring  the  power 
of  immediate  subordination  of  his  own  desire  to  what  after 
all  must  be  done  sometime.  For  instance,  a  boy  who  cannot 
understand  the  rationale  of  bacterial  infection  is  forbidden 
to  take  milk  unless  boiled.  The  mandate  can  be  enforced 
by  the  suggestion  that  boiled  milk  is  a  delicacy,  and  that  he 
is  privileged  in  being  permitted  to  have  it;  but  this  procedure 
is  quite  unnecessary  when  a  mere  affirmation  should  suffice, 
which,  moreover,  will  prevent  the  danger  of  his  foregoing  the 


1JO  Psychotherapeutics 

privilege,  in  order  to  drink  raw  milk.  The  advantage  of 
assured  obedience  to  authority  is  most  manifest  during  such 
periods  of  emotional  motor  or  intellectual  hyperexcitability 
as  precede  exhaustion.  They  may  be  compared  to  the  para- 
lytic secretion  of  the  physiologists.  Hence  the  more  simple 
the  brake  used  the  better,  for  complex  means  of  arrest  only 
increase  the  cerebral  activity. 

Another  example  of  a  misapplication  of  suggestion 
consists  of  saying  to  a  child,  "  You  are  not  afraid,"  when  he 
shows  timidity  in  some  unusual  situation.  The  child  knows 
quite  well  that  the  mere  making  of  the  remark  indicates  a 
reason  for  fear;  and  the  real  effect  produced  is  the  suggestion 
of  fear,  which  might  have  been  avoided  by  assuming  a  matter 
of  fact  manner  as  soon  as  indications  of  hesitancy  or  timidity 
were  shown  by  the  child,  taking  care  at  the  same  time  to 
replace  the  unpleasant  affective  mode  by  another,  through 
substitution  and  distraction.  Of  course,  reliance  on  simple 
affirmation  must  be  maintained  by  truthfulness,  and  later  by 
reasonableness. 

The  habits  of  accuracy  and  orderliness  may  be  incul- 
cated without  the  danger  of  their  becoming  besetments, 
if  it  is  done,  so  to  speak,  spontaneously  as  a  pleasure,  and 
not  as  a  duty  Calvinically,  that  is,  if  it  is  made  kinetic  rather 
than  inhibitive.  For  example,  a  boy  of  two  and  a  half  is 
asked  to  bring  in  two  balls  with  which  he  was  playing  in  the 
garden,  and  later  to  pick  out  from  some  others  those  he 
brought.  This  exercise  not  only  cultivates  memory  and 
accuracy,  but  the  power  of  perception  of  difference  as  well 
as  the  notion  of  responsibility  and  the  pleasure  in  having  it 
recognized. 

A  boy's  whole  world  of  fitness  is  upset  when  unusual 
acts  are  done.  A  boy  of  three  will  allow  no  one  else  to 
touch  the  letters  placed  on  his  father's  plate.  After  playing 
with  his  father  and  wanting  "  more  fun,"  he  would  not 
desist  from  his  demands  when  told  it  was  too  hard  for  his 


Psychoprophylaxis  in  Childhood  171 

father,  replying  "  not  too  hard,"  but  at  once  did  so  when  told 
"  Father  tired."  He  recognized  this  from  his  mother's  and 
his  own  experience  as  a  valid  excuse  for  stopping. 

These  habits  become  morally  imperative  (19),  and  are 
very  hard  to  eradicate  in  after  life,  for  they  do  not  depend 
upon  clarity  of  conception,  as  is  well  shown  by  the  fact  that 
most  of  us  do  not  act  entirely  in  accord  with  our  intellectual 
convictions,  but  persist  in  regulating  our  conduct  by  doctrines 
long  outgrown.  Hence,  the  importance  of  preventing  the 
feeling  of  dependence  by  encouraging  the  child's  desire  for 
and  pride  in  performing  tasks  about  the  house  and  garden. 
If,  for  instance,  a  child  is  encouraged  to  put  on  hi  s  own 
clothes  under  the  belief  that  it  is  a  clever  act  or  to  wash 
itself,  these  actions  will  become  automatic,  and  he  will  not 
later  have  to  go  through  the  difficult  acquisition  of  the  clean 
hand  instinct  and  that  of  self-helpfulness  (20). 

The  ineradicability  of  fear  when  inculcated  in  early 
childhood  is  clearly  illustrated  by  the  Southern  lady,  who 
even  in  advanced  age  dared  not  go  alone  into  the  dark, 
although  she  has  long  ceased  to  believe  in  the  stories  which 
first  made  her  afraid  to  do  so.  She  realized  this  so  forcibly 
that  she  would  not  permit  her  three  daughters  to  be  told  any 
of  the  alarming  stories  which  most  Southern|children  learn. 
Her  psychoprophylaxis  resulted  in  the  girls  never  having 
known  what  it  meant  to  be  afraid  in  the  dark.  Indeed,  it 
was  the  habit  of  their  schoolfellows  to  send  them  into  dark 
and  eerie  places  to  show  off  their  powers.  The  tenacity  of 
early  affects  is  again  illustrated  by  the  immovable  depression 
produced  by  the  playing  of  gospel  hymns  on  a  reed  organ  in 
the  case  of  a  lady  in  whose  childhood  the  Calvinical  Sunday 
had  almost  caused  fear.  The  psychoprophylaxis  here  is 
obvious  (21).  In  another  case  the  hearing  of  a  brass  band 
invariably  produces  weeping  and  terror.  This  is  due  to  the 
fact  that  such  playing  occurred  during  the  horrors  of  the 
civil  war. 


172  Psychotherapeutics 

In  some  children  (22)  care  is  needed  to  avoid  the 
'  besoin  d'etre  aime"  the  craving  for  sympathy.  This  may 
be  induced  by  excessive  petting  and  loving  while  a  child  is 
tired  or  after  injury.  It  is  better  to  send  the  child  to  bed 
when  tired  and  to  divert  his  attention  when  injured.  But 
denial  of  sympathy  is  equally  bad,  and  is  the  cause  of  the 
intense  love  hunger  seen  in  many  young  people  whose  sur- 
roundings have  suppressed  their  natural  affection. 

It  must  be  remembered  that  the  fundament  of  altruism 
lies  in  the  afFectivity  (23),  and  this  must  not  be  suppressed, 
but  must  be  controlled  and  used.  For  instance,  during 
sympathy,  interest  may  be  aroused  and  turned  into  an  un- 
related channel,  and  thus  used  for  moral  and  intellectual 
teaching  instead  of  being  roughly  ignored. 

These  may  appear  small  matters,  but  they  illustrate 
important  principles,  as  will  appear  when  they  are  applied 
to  the  matter  of  lying  and  the  acquisition  of  the  sense  of  re- 
sponsibility and  right  conduct. 

The  mythomanic  (24)  tendency,  which  is  responsible 
for  so  many  medico-legal  difficulties,  would  be  much  dimin- 
ished by  a  psychoprophylaxis  addressed  to  the  afore- 
mentioned habit  of  accuracy;  for  the  conduct  indicated  is 
merely  a  mode  of  truth  in  act,  which  to  a  child  precedes  the 
significance  of  truth  in  speech.  The  latter  is  discouraged, 
I  believe,  by  mystery  tales,  as  well  as  by  those  of  voodoo, 
though  I  am  aware  that  much  difference  of  opinion  on  this 
point  exists  among  pedagogues.  I  cannot  enlarge  upon  this 
theme,  except  to  point  out  how  often  mythomanic  manifesta- 
tions are  miscalled  hysteria  by  medical  men  who  have  been 
unduly  impressed  by  the  doctrines  of  Charcot  (25);  whereas, 
the  difference  has  been  clearly  pointed  out  by  Dupre  (26) 
and  Babinski  (27).  The  newspapers  of  the  day  afford  in- 
numerable examples  of  the  dishonest  point  of  view  which 
eventuates  in  mythomania.  It  is  almost  entirely  preventable 
by  a  proper  psychoprophylaxis,  if  not  on  the  part  of  the 


Psychoprophylaxis  in  Childhood  173 

parents,  then  later  and  with  more  difficulty  on  the  part  of 
the  schoolmaster. 

In  this  connection,  I  must  express  the  belief  of  the  need 
for  men  in  the  moral  training  of  boys.  The  best  elements 
of  moral  development  are  inculcated,  not  in  the  schoolroom, 
but  at  play,  in  which  the  masters  must  participate  more  or 
less:  and  as  at  present  trained,  very  few  women  are  capable 
of  this.  The  revolution  effected  in  the  habits  or  character 
of  the  English  school  boy  by  the  methods  of  Thomas  Arnold 
of  Rugby  (28)  afford  a  striking  illustration  of  this. 

To  attempt  to  manage  boys  by  religious  sentimentalism 
and  softness,  the  woman-and-slave  morality  of  Neitzsche  (29) 
is  to  encourage  hypocrisy  in  the  strong  and  the  exaggeration 
of  weakness  in  the  feeble.  Of  course  sympathy  must  be 
used,  but  it  must  be  a  manly  one,  referring  mainly  to  the 
forceful  activities  of  the  life  of  a  normal  boy.  In  this  way 
a  self-reliant  character  is  built  up  by  the  encouragement  of 
constant  relation  of  itself  to  the  welfare  of  a  society  in  the 
responsibilities  of  which  each  boy  has  a  separate  niche  to 
fill. 

Than  this  there  is  no  better  prophylactic  against  de- 
spondency, suspiciousness,  and  other  anti-social  feelings  of 
paranoid  type.  By  this  system  of  encouraging  morality  to 
become  constantly  kinetic  and  to  be  thought  of  and  con- 
trolled by  its  relation  to  others  while  self-respect  is  main- 
tained, the  hyper-suggestibility  is  restricted  and  hysteria 
prevented. 

Psychasthenic  types  too  are  not  apt  to  develop  in  an  en- 
vironment where  solitariness  is  impossible,  and  where  the 
stresses  are  healthy  and  kinetic,  and  the  emotional  and  intel- 
lectual appeals  are  of  a  positive  and  clear  comprehensibility. 
Hence  the  rarity  of  psycho-neuroses  in  the  men  who  have 
been  trained  in  the  public  schools  of  Great  Britain.  And 
their  influence  has  not  ceased  here;  for  the  habits  of  conduct 
illustrated  and  brought  into  prominence  by  Arnold's  boys 


174  Psychotherapeutics 

have  permeated  the  whole  national  life,  with  the  result  that 
De  Fleury  (30)  has  been  able  to  comment  with  admiration 
upon  the  freedom  of  the  nation  from  the  psycho-neuroses,  the 
study  of  which  has  given  such  distinction  to  French  neurolo- 
gists. 

Similar  methods  may  be  applied  with  success  even  to 
boys  perverted  by  faulty  environment;  for  instance,  Tomlins 
(37)  developed  a  thieving  jail  boy  into  a  useful  ctizen  by 
reversing  the  mawkish  treatment  he  had  been  re- 
ceiving in  the  reformatory,  and  substituting  a  peremptory 
and  rough  method  of  making  him  responsible  for  certain 
duties  and  for  other  boys,  and  showing  surprise  that  he  did 
not  do  better  work  than  he  at  first  showed. 

On  the  other  hand,  there  is  the  case  of  a  girl  in  whom 
intractable  fits  of  temper  were  cured  by  one  display  of 
kindly  sympathy  after  she  had  torn  up  her  books  in  a  fit  of 
rage.  The  prophylaxis  in  each  of  these  cases  meant  the  sav- 
ing of  a  whole  life  from  the  misery  which  would  have  arisen 
in  a  purely  psychogenetic  way. 

The  psychological  insight  which  enabled  the  reflexes 
to  be  "  conditioned  "  in  these  two  cases  is  responsible  for 
these  two  useful  lives. 

Many  a  phobia  or  angoisse  can  be  prevented  by  psychic 
means.  Similar  in  principle  are  the  means  to  be  employed 
against  the  self-distrust  and  diffidence  of  the  psychasthenic 
form  of  insufficiency.  The  natural  desire  of  a  child  to  play 
with  its  fellows  will  soon  disappear  if  he  is  too  slow-witted 
to  comprehend  the  game  or  too  clumsy  to  take  his  due  part, 
or  is  constantly  humiliated  by  his  failure  or  by  the  mockery 
of  his  fellows.  Want  of  capacity  in  some  study  arising  from 
the  defect  of  some  motor  sensorial  or  associational  process 
may  produce  a  self-deprecatory  or  anxious  attitude  very  un- 
favorable to  healthy  psychic  development  and  most  provoca- 
tive of  the  scrupulosity  of  psychasthenia. 

The  method  of  conditioning  the  reflexes  is  illustrated 


Psychoprophylaxis  in  Childhood  175 

most  clearly  by  human  beings  in  cases  of  sexual  perversion 
where  some  artificially  introduced  element  becomes  the 
efficacious  provoker  of  future  sexual  desire,  or  at  least  satis- 
faction. The  genesis  of  the  fetich  constitutes  the  condition- 
ing of  the  sexual  reflex  in  that  person. 

The  whole  element  of  the  sexual  element  in  the  causa- 
tion of  the  psycho-neuroses  is  too  long  to  discuss  here.  I 
must,  however,  deplore  the  difficulties  thrown  in  the  way  of 
the  study  of  these  very  important  problems  of  psycho- 
prophylaxis  by  the  unwillingness  of  some  observers  to  in- 
vestigate the  sexual  life  of  their  patients.  To  establish  a 
solid  psychoprophylactic  doctrine  we  need  accurate  informa- 
tion, and  the  scientific  search  for  such  information  must  not 
allow  itself  to  be  hampered  by  national  prudishness.  It  is 
this  noli  me  tangere  perversion  of  morality  which  arro- 
gates to  itself  the  exclusive  title  of  morality  which  is  respon- 
sible for  much  of  the  prurient  attitude  of  the  young  towards 
sexual  relationship. 

What  shall  we  think  of  a  civilization  which  permitted 
a  highly  respected  woman  physician  of  twenty  years'  standing 
to  be  placed  in  jail  for  having  written  a  book  instructing 
young  women  upon  sexual  hygiene  ?  This  actually  happened 
less  than  five  years  ago  in  Chicago.  Such  an  attitude  fosters 
ashamedness  in  the  young;  and  shame  of  the  bodily  func- 
tions as  we  know  frequently  dominates  the  field  of  conscious- 
ness of  a  psychasthenic.  An  adolescent  who  has  been  dis- 
couraged from  discussing  or  understanding  the  phenomena 
even  of  his  own  sexual  life  and  taught  to  regard  them  as 
different  in  kind  from  other  facts  of  personal  function  and 
hygiene  is  sadly  handicapped  in  the  difficult  process  of 
somato-psychic  or  allo-psychic  adjustment  in  that  difficult 
period  of  his  life. 

Similar  animadversion  may  be  made  against  what  is  now 
less  common  — the  state  of  apprehension  and  terror  induced 
by  religious  teachings  founded  upon  the  doctrine  of  man's 


1 76  Psychoth  erapeutics 

inherent  evil  nature  and  damnableness.  A  research  by  Coe 
showed  that  less  than  ten  years  ago  a  very  large  percentage 
of  college  students  had  suffered  severely  from  the  spiritual 
agonies  of  the  attempt  to  reconcile  their  dawning  knowledge 
of  the  universe  with  the  inadaptive  and  injurious  doctrines 
they  had  been  taught  in  the  name  of  religion  and  morality. 

Now  it  is  very  simple  to  forestall  such  morbid  reaction 
by  directing  the  activity  of  such  children  into  channels  for 
which  they  show  aptitude.  From  the  feeling  of  accom- 
plishment and  triumph  thus  engendered  the  child  will 
gradually  learn  to  adjust  himself  to  difficulties  which  mental 
prepossessions  and  inertia  would  have  rendered  impossible 
to  overcome.  A  delusion  of  persecution  so  often  fertile  in 
dangerous  reactions  has  really  its  source  in  a  mistrust  and 
suspiciousness  which  might  have  been  prevented  or  removed 
by  the  self-satisfaction  coming  from  the  fulfilled  desire  of 
productive  activity.  The  delusion  is  essentially  a  defense 
reaction  against  the  feeling  of  self-distrust.  Such  feeling  is 
powerfully  conduced  to  by  cultivating  in  children  a  pride  not 
consonant  with  their  true  relation  to  others;  for  the  social 
activities  of  such  children  will  be  contaminated  by  an  ex- 
aggerated self-respect  which  will  necessarily  be  constantly 
wounded,  whence  an  inevitable  withdrawal  from  social 
activities  which  do  not  minister  to  their  pride,  and  therefore 
an  ever-increasing  seclusion  which  is  more  and  more  domi- 
nated by  suspicious  inferences  from  innocent  words  and  acts  of 
others  and  brooding  thereupon  until  this  ideational-emo- 
tional  complex  dominates  and  becomes  the  character  of  the 
person  and  refractory  to  intervention;  but  the  psychoprophy- 
laxis  would  have  been  simple,  and  is  obvious. 

The  gastric  neuroses  are  a  striking  example  of  the 
non-use  of  psychoprophylactic  power  by  medical  men :  for 
the  great  majority  of  these  cases  occur  as  the  result  of  the 
suggestions  of  medical  men  while  prescribing  for  patients 
suffering  from  temporary  indigestion  (33)  or  by  the  indirectly 


Psychoprophylaxis  in  Childhood  177 

gained  notions  of  medical  origin  with  regard  to  eating  and 
diet.  Again,  recent  work  has  shown  the  difference  between 
tic  and  true  chorea,  and  also  that  the  latter,  now  clearly  shown 
to  be  an  organic  disease  (37)  may  begin  by  intellectual  and 
emotional  perturbations  long  before  the  motor  areas  are 
affected. 

The  only  practical  way  of  detecting  these  early  condi- 
tions is  through  medical  inspection  of  school  children  by 
trained  neurologists  whose  knowledge  of  physical  and  mental 
test  signs  will  anticipate  many  a  breakdown,  besides  remov- 
ing from  the  other  children  the  contagion  which  habit-spasm 
and  chorciform  movements  are  known  to  exercise  on  their 
plastic  minds.  As  a  matter  of  fact  the  co-operation  which 
should  be  sought  is  much  less  that  of  the  priest  than  that  of 
the  teacher  of  the  young.  We  can  hope  to  influence  him  to 
a  scientific  attitude  toward  the  biological  phenomena  with 
which  he  deals;  besides  which  the  help  in  managing  difficult 
and  neurotic  children  which  he  gains  from  neurological 
advice  makes  him  very  ready  to  welcome  it,  as  my  experience 
shows. 

And  indeed  pedagogues  themselves  have  noticed  the 
need  of  medical  psychoprophylaxis.  Thus  Swift  (loc.  cit.) 
says,  "  Half  an  hour's  observation  of  pupils  at  their  school 
work  will  convince  one  skilled  in  interpreting  nerve  signs 
that  nervous  disorders  have  become  so  common  as  to  menace 
our  national  health,  and  the  significance  of  this  for  educa- 
tion has  been  too  generally  ignored."  And  again  further, 
"  It  is  unfortunate  that  instincts  are  so  frequently  the  child's 
only  defense  against  pedagogical  enlightenment  (sic)  medical 
supervision  cannot  fully  meet  the  need  unless  a  nervous 
affection  is  detected  in  its  incipiency;  so  the  teacher  must  be 
taught  about  the  early  signs,  so  as  to  call  in  a  physician  to 
prevent  aggravation  by  the  continued  irritation  of  test  and 
examination."  r  1 

As  desirable  would  be  the  teaching  of  the  mothers  to 


178  Psychotherapeutics 

form  healthy  emotional  habits  in  their  children.  The  happy- 
go-lucky  absolutism  which  so  often  asserts  itself  as  capacity 
is  sadly  defective  as  such  a  guide  for  hesitating  childhood. 
The  management  of  the  mind  and  the  emotions  into  a 
morality  constitutes  the  most  difficult  study  and  art.  But  it 
can  hardly  be  expected  that  fortitude  can  be  inculcated  by 
a  mother  who  has  not  herself  shown  it  sufficiently  to  even 
attempt  to  understand  the  biological  laws  upon  which  de- 
pend the  reactions  of  the  nervous  system  which  we  call 
conduct,  for  the  ethics  taught  to  most  children  is  a  vestige  of 
medievalism  conspicuous  for  its  poverty  in  such  criteria  of 
modern  civilization  as  justice,  liberty,  courtesy,  altruistic 
sympathy.  The  child's  natural  good  impulses  are  checked 
and  twisted;  when  his  reasoning  from  cause  to  effect  is  not 
neglected  or  obstructed,  he  is  thus  confused  and  finally  often 
discouraged  into  sadness  or  indifference,  becoming  as  a  man 
either  despondent  or  happy-go-lucky,  with  either  no  morality 
or  one  of  words  only,  which  has  no  efficacy  in  preventing 
maladjustment. 

But  a  morality  which  is  really  active  instead  of  being 
merely  received  on  faith  becomes  a  part  of  a  boy's  character 
and  is  carried  out  in  his  conduct.  It  intertwines  with  his 
every  thought  often  quite  unconsciously.  Suggestions  con- 
trary to  this  trend  are  then  automatically  repulsed,  and  we 
secure  reliability  of  conduct;  and  socially  speaking  that 
power  of  prediction  which  gives  security  in  man's  relationship 
with  man. 

Now  this  may  appear  hardly  a  medical  but  more  a 
sociological  matter;  but  there  is  no  difference  of  kind  be- 
tween a  perversion  of  conduct  which  we  call  criminal,  that  is, 
anti-social,  and  an  aberration  proceeding  from  ideas  which 
we  call  hysterical.  The  false  belief  that  one's  limbs  are  in- 
capable of  locomotion  or  the  comfortable  and  cherished 
feeling  that  one  is  an  invalid  and  unable  to  support  one's  self 
are  both  anti-social  attitudes,  in  whatever  good  faith  they  are 
assumed. 


Psychoprophylaxis  in  Childhood  179 

Now  their  prevention  as  well  as  their  cure  is  the  pre- 
rogative and  duty  of  medical  science,  which  is  called  upon 
to  distinguish  from  the  aberrations  of  conduct  due  to  the 
changes  in  the  secretions,  and  the  nervous  system  those  due 
to  aberrant  notions.  And,  nowadays,  as  this  symposium 
shows,  we  have  to  apply  the  remedy,  not  only  to  the  former, 
but  the  latter  in  supplementing  the  activities  of  the  pedagogue 
and  priest  with  the  special  means  the  psychiatrist's  training 
permits;  that  is  to  say,  when  a  pathological  type  of  reaction 
has  been  constituted  by  the  hurtful  suggestions  of  a  faulty  en- 
vironment, it  is  the  doctor's  province  to  eradicate  the  hurtful 
suggestions  and  to  emplant  a  habit  of  mind  tending  for  the 
good  of  society  and  refractory  to  suggestions  contrary  to  that 
object.  For  a  close  analysis  shows  that  the  real  cause  of 
most  so-called  "  nervous  prostration  "  is  failure  of  adjust- 
ment to  environment,  and  is  psychogenetic.  A  rest  cure  in 
itself  is  inefficacious,  but  gives  the  doctor  the  opportunity 
to  re-educate  the  perverted  trends  of  the  patient's  disposition. 
Before  reaching  the  neurologist,  a  patient  has  been  "  sug- 
gestioned  "  ad  nauseam:  and  such  empirical  therapy  has 
failed,  as  has  the  injudicious  appeal  to  his  will  power  already 
exhausted  by  the  complexities,  social  and  professional, 
which  have  contributed  to  his  failure  of  adjustment. 

To  arrest  a  morbid  train  of  thought  and  set  a  mind  at 
rest  is  an  art  requiring  knowledge  and  skill.  Its  attempt  by 
untrained  men  has  been  even  more  disastrous  than  the  work 
of  the  tyro  in  gynaecology;  for  it  is  the  direct  cause  of  the 
rise  of  Christian  Science,  Emmanuelism,  and  such  cults. 
Happily,  a  body  of  experts  in  psychopathology  is  now 
counteracting  their  injurious  influence:  for  an  affectation  of 
knowledge  will  not  supply  the  public's  demand  for  real 
psychic  treatment.  But  we  require  greater  facilities  for 
instructing  medical  men  in  the  principles  of  psychopa- 
thology and  therapeutics;  and  proper  wards  and  out-patient 
clinics  under  competent  teachers  should  be  provided,  at  least 
in  every  large  city. 


1 80  Psychoth  erapeutics 

REFERENCES 

1.  Grasset.     Therapeutique  des  Maladies  du  Systeme  Nerveux.     Paris, 

1907. 

2.  The  Huxley  Lecture,  Brit.  Med.  Jour.  1906.    Vol. 

3.  See  Morton  Prince.    The  Unconscious.  JOUR.  ABNOR.  PSY.  1909,  Dec. 

Friedmann  and  Gierlich  Studies  in  Paranoia.     Trans.  Nervous  and 
Mental  Series,  N.  Y.,  1908. 

4.  Suggestion  and  Persuasion.     Alienist  and  Neurologist,  1909,  May. 

5.  Rev.  Neurologique.     1907. 

6.  Camus  et  Pagniez.     Isolement  et  Psychotherapie.     Paris,  1904. 

7.  The  Relation  of  the  Med.  Prof,  to  the  Psychotherapeutic  Movement. 

Boston  Med.  Jour.,  1908. 

8.  Riv.  Sper.  di  Phren.  et  Psy.,  1908. 

9.  Janet,  Les  Oscillations  du  Niveaux  Mentale  Congres  de  Rome,  1904. 

10.  Williams,  The   Differential   Diagnosis    between    Neurasthenia    and 

Some  Affections  of  the  Nervous  System,  for  which  it  is  often  mistaken. 
Archives  of  Diagnosis,  1909,  Jan. 

11.  Williams.     Hints  on  Psychotherapy.     Monthly  Cyclopedia,  1908. 

12.  Lecons  Cliniques.     1907.     (Unpublished). 

13.  Mind  in  the  Making.    New  York,  1908. 

14.  Williams,  Discussion  on  Responsibility  of  Hysteria.     Contes  rendues 

Congres  de  Lille,  1906. 

15.  La  Suggestibilite.     Paris,  1897. 

16.  Jastrow.     Fact  and  Fable  in  Psychology.    N.  Y.  and  London,  1907. 

17.  See  O'Shea,  The  Dynamic  Factor  in  Education,  1904.      N.  Y. 
Archibald,  The  Power  of  Play.     London,  1908. 

18.  Raymond  et  Janet,  Les  Obsessions  et  la  Psychasthenic.     Paris,  1903. 

19.  Leuba.    The  Nature  of  the  Moral  Imperative,  Amer.  Jour.  Psy.,  1897. 

20.  See  Williams,  The  Psychological  Bases  of  Inebriety.     New  York  Med. 

Jour.,  1909,  April.     Also  Pedag.  Seminary,  1909. 

21.  See  White,  Theory  of  the. Complex,  Interstate  Med.  Jour.,  1908,  April 

Morton  Prince,  loc.  cit.  Chap.  1 1. 

22.  Raymond  et  Janet,  loc.  cit. 

23.  Spencer,  The  Data  of  Ethics. 

24.  Dupre,  La  Mythomanie.     Paris,  1906. 

25.  See  such  current  text  books  as  Saville,  Church,  and  Petersen. 

26.  Loc.  cit. 

27.  Ma  Conception  de  1'Hysterie.     Paris,  1906.     La  Demembrement  de 

1'Hysterie.     Semaine  Medicale.     1909. 

273.  The  Trend  of  the  Clinician's  Concept  of  Hysteria.     Boston  Med.  and 
Surg.  Jour.,  1909.     March  25. 


Psychoprophylaxis  in  Childhood  181 

28.  See  Tom  Brown's  School  days  and  Numerous  Lives. 

29.  Mancken,  The  Philosophy  of  Neitzche.     New  York,  1908. 

30.  Le  Figaro.     Paris,  1906. 

31.  Communicated  verbally. 

32.  See  Williams.     The  Most  Frequent  Cause  of  Nervous  Indigestion, 

Jour.  Abnor.  Psy.,  1909,  Feb.  Also  Amer.  Med.  1909,  April.  Old 
Dom.  Jour.,  1908,  Nov.  Degerine  Les  Fausse  Gastropaths,  Presse 
Med.,  1906. 

33.  Le  Role  du  Medecin  en  creant  ou  en  maintainant  par  ses  Suggestions 

Maladroites  les  Maladies  produites  par  I'lmagination.  Congres  des 
Neurologists  £  Lille,  1906.  Trans.  Amer.  Med.,  1908,  Aug. 

34.  Steherback,  Arch,  de  Neur.,  1709. 

35.  The  Psychology  of  the  Spiritual  Life,  Chicago  &  New  York,  1904. 

36.  Meige  et  Feindehl,  Les  Tics  et  leurs  Traitements.     Paris,  1901. 
Williams,  Differential  Diagnosis  of  Tics  &  Spasms  Via  Semi-Monthly, 

1908. 

37.  Payne  et  Poynton,  The  Etiology  of  Chorea,  Brit.  Med.  Jour.,  1906. 

38.  Burr,  President's  Address,  Jour.  Nerv.  et  Ment.  Disease,  1908. 


THE  RELATION  OF  CHARACTER  FORMATION 
TO  PSYCHOTHERAPY 

BY  JAMES  J.  PUTNAM,  M.D., 
Professor  of  Neurology,  Harvard  Medical  School 


THE   RELATION  OF  CHARACTER    FORMATION 
TO  PSYCHOTHERAPY 

MY  object  in  this  paper  is,  first,  to  indicate  the  place 
of  a  study  of  character  in  a  scheme  of  psycho- 
therapy;  next,  to  define  what  we  mean  by  char- 
acter;  and  lastly,  to  point  out  how  far  it  is  reason- 
able to  expect  to  modify  character  and  under  what  principles 
this  is  to  be  attempted. 

The  word-^haiLacter  will  be  here  employed  in  its  usual 
double  sense;     first,  as  in  describing  the  prevailing  tenden 

ir  value  as~reaFd 


ies  of  a  ma"*«  Kfff  with™^  ™»farfinff> to  their  value  as  regards 
the  securing  of  results;  next,  as  a  sort  of  estimate  of  value  — 
intellectual,  esthetic,  moral,  volitional, —  of  these  various 
tendencies. 

In  accordance  with  the  former  of  these  two  meanings 
we  might  speak  of  a  person  as  being  sanguine  or  volatile, 
stolid  or  visionary,  dependent  or  independent,  etc.  In 
accordance  with  the  second  meaning  we  might  speak  of 
him  as  being  a  man  "  of  character,"  meaning  thereby  that 
he  was  of  "  fine  "  or  "  strong  "  character.  It  is  needless 
to  say  that  these  terms  "  fine  "  and  "  strong  "  have  a  relative 
significance,  but  into  this  consideration  we  need  not  enter 
here.  The  antithesis  between  these  two  meanings  of  the 
word  character  is  best  shown  when  we  say  of  a  person,  as  we 
clearly  may,  that  his  character  is  to  be  defined  as  consisting 
in  an  absence  of  character.  It  will  be  seen  that  the  various 
terms  hitherto  used  for  the  designation  of  character  will 
have  to  give  place  to  others  of  more  exact  scientific  meaning, 
or  else  to  get  themselves  reclothed  with  connotations  of  a 
new  sort,  but  the  word  character  is  likely,  none  the  less,  to 
preserve  its  double  signification. 

It  must  be  evident  to  every  one  who  looks  closely  at  the 
facts,  that  the  therapeutic  efforts  of  those  physicians  who 

185 


1 86  Psychotherapeutlcs 

concern  themselves  especially  with  the  study  of  the  functional 
psychoses  have  been  rapidly  developing  on  new  and  interest- 
ing lines.  The  neurologists  of  the  present  day  tend  less 
and  less  to  treat  the  nervous  invalids  entrusted  to  their  care 
in  accordance  with  the  principles  of  a  narrow  militarism  or  as 
subjects  for  cajoling,  and  more  and  more  as  reasonable 
beings  possessed  of  consciences  and  independent  wills  and 
capable  of  intelligent  co-operation.  In  proportion  as  our 
knowledge  of  the  mental  life  has  become  deeper  and  more 
accurate  there  has  been  a  growing  tendency  to  seek  further 
and  further  for  the  causes  of  distressing  mental  symptoms, 
whether  these  causes  lie  in  the  environment  of  the  patients 
or  in  habits  and  instincts  and  experiences  dating  back  to  the 
years  of  childhood  or  expressed  in  inherited  physical  traits. 
Hand  in  hand  with  these  tendencies  towards  a  more  searching 
analysis  of  symptoms  with  reference  to  this  origin  there  has 
come  a  willingness  to  undertake  a  modification  of  the  mental 
mechanism  such  as  was  not  characteristic  of  the  therapeutic 
efforts  of  earlier  days.  Success  in  these  efforts  constitutes 
the  triumphs  of  modern  neurological  practice.  The  more 
complex  of  these  methods  might  be  described  as  constituting 
the  major  surgery  of  this  form  of  therapeutics,  since  to 
utilize  them  at  their  best  requires  both  skill  and  insight 
and  willingness  to  expend  a  vast  amount  of  time  for  the 
accomplishment  of  the  results.  The  modern  practice  has 
come  more  and  more  to  deserve  the  name  of  ^education.  \ 
Less  effort  is  now  made  to  shunt  out  the  critical  powers 
and  instincts  of  our  patients;  greater  effort  to  lead  them 
into  paths  of  intelligent  insight.  Hypnosis  is  less  often 
used  for  the  purposes  of  pure  suggestion,  while  the  induction 
of  hypnoid  states,  for  the  purposes  of  analysis,  and  through 
analysis,  of  treatment,  has  become  more  common,  and  even 
this  method  is  giving  place  to  kinds  of  mental  probing  in 
which  the  patient  takes  a  conscious  and  a  willing  part. 
"  Isolation  cures  "  and  "  work  cures,"  valuable  as  they  are, 


' 


Relation  of  Character  Formation  to  Psychotherapy     187 

are  found  to  yield  their  best  results  when  made  parts  of  a 
broad  system  of  education.  The  final  aim  of  the  isolation 
should  be  social  life,  in  its  best  sense,  and  work  done  by  the 
invalid  should  lead  to  work  done  for  the  social  welfare.  In 
the  same  sense,  rules  of  living  are  found  to  yield  their  best 
results  when  made  subservient  to  principles  of  living,  and 
success  in  treatment  is  estimated,  not  so  much  by  the  disap- 
pearance of  symptoms  as  by  the  appearance  of  a  thoughtful  y* 
individual,  liable  to  fail,  but  competent  to  use  his  failures  in 
the  interests  of  progress. 

It  is  on  the  basis  of  a  firm  belief  in  the  value  of  these 
new  forms  of  inquiry  into  the  mental  life  that  the  following 
remarks  on  character  are  offered.  The  object  of  these  new 
and  searching  inquiries  is  to  make  us  intimately  acquainted 
with  the  nature  of  the  man  with  whom  we  have  to  deal. 
But  it  is  precisely  in  attempting  to^define  his  character  that 
we  put  this  knowledge  to  the  best  test.  For  the  character 
is  the  epitome  of  the  man.  It  is  no  longer  enough  to  char- 
acterize a  man  as  "  self-centered,"  "  irresolute,  "  "  dominated 
by  envy,  suspicion,  jealousy;  "  or,  on  the  other  hand,  as  a 
person  of  "  fine  "  or  "  strong  "  character,  as  if  we  had  the 
right  to  assume  that  we  had  thereby  added  something  ma- 
terial to  our  knowledge  of  him,  in  a  scientific  sense.  If  the 
person  in  question  is  not  unified^ in  respect  to  his  mental 
states,  but  "  dissociated T^aTtKrough  strong  emotional  strain 
or  through  even  moderate  emotional  strain  acting  on  tenden- 
cies already  physiologically  unstable;  in  other  words,  if  he  is 
a  "  hysteric,"  with  contracted  field  of  mental  vision,  then  of 
course  he  is  self-centered,  and  the  physician's  duty  is,  not  to 
blame  him  but  to  recognize  him,  to  see  that  he  is  not  mis- 
judged, and  if  possible  to  cure  him. 

The  truth  is  that  ever  since  the  day  when  medical  ob- 
servation first  began  to  intrude  itself  definitely  into  the  field 
of  psychology,  a  new  vocabulary  and  new  synonyms  have 
been  more  and  more  demanding  recognition. 


1 88  Psychotherapeutics 

It  is  as  true  in  the  mental  as  it  is  in  the  physical  field 
that  "  disease  is  but  health  under  altered  conditions  "  and 
that  many  a  moral  ban  of  the  conventional  social  judge  will 
have  to  give  way  before  a  truer  re-statement  of  the  facts  than 
our  ignorance  had  known.  So  far  as  we  can,  then,  let  us 
in  the  future  strive  to  infuse  new  meaning  into  our  concep- 
tions of  the  terms  character  and  characters.  Let  us  be 
more  chary  of  roughly  grouping  men  as  bad,  selfish,  or  weak 
in  character,  and  more  ready  to  search  diligently  for  the 
exact  influences  that  made  them  what  they  are.  Nothing 
happens  by  pure  chance. 

The  most  fruitful  work  in  the  way  of  mental  analysis, 
and  therefore  incidentally,  of  character  analysis,  has  been 
that  which  has  centered  round  the  observations  of  Janet,  «* 
of  Bergson,  and  of  Freud  —  to  mention  only  a  few  of  the 
foremost  names  —  and  the  main  object  of  their  researches 
has  been  to  discover  thejnfluence  of  the  unseen  mentaljife. 
Most  people  feel  as  if  they  could  point  distinctly  to  the 
influences  that  have  shaped  their  characters  and  conduct. 
But,  in  fact,  the  necessity  of  action,  the  necessity  of  social 
conformity,  force  our  choices,  narrow  our  vision,  and  compel 
mental  conflicts  which  take  a  silent  part  in  shaping  the  habits 
and  tendencies  of  response  that  we  call  our  characters. 
Thus  the  lives  even  of  the  best  men  are  compromises, 
adaptations  for  more  or  less  special  ends.  It  has  often 
been  pointed  out  of  late  years  what  an  important  part  emo- 
tion and  emotional  interests  play  in  determining  the  current  i 
of  our  thought  and  actions,  and  that  when  a  painful  emotion  ; 
is  suppressed  it  is  apt  to  carry  with  it  a  cluster  of  memories  j 
into  a  species  of  oblivion.  But  this  grouping  of  mental 
processes  around  emotions,  which  gives  a  tendency  to  our 
thoughts  to  recur  in  "  constellations  "  rather  than  isolated, 
one  by  one,  typifies  the  construction  of  our  mental  lives  in 
general.  It  is  therefore  theoretically  explicable  that  the 
tendency  to  the  formation  of  double  or  multiple  lives,  or  to*t 


Relation  of  Character  Formation  to  Psychotherapy    189 

what  has  been  called  dissociation  and  reassociation  on  new 

lines,  should  occur  to  a  certain  extent  not  only  in  hysteria, 

but  under  conditions  commonly  called  normal.     It  can  be 

understood  on  the  same  principle  how  a  person's  character 

,  may  be  double,  and  inasmuch  as  our  subconscious  mental 

J  lives,  those  portions  of  ourselves  which  we  exclude  from  the 

(  focus  of  our  immediate  interest,  are  far  more  comprehensive^ 

'•than  our  lives  of  self-conscious  awareness,  it  is  also  com- 

•prehensible  that  large   tendencies   and  even   personalities, 

Ipach  expressible  in  condensed  form  as  character,  should 

exist  side  by  side  and   affect  our  conduct  without  being 

readily  observable  in  and  for  themselves. 

Equally  important  with  this  principle  of  dissociation 
and  reassociation  is  the  principle  of  the  persistence  into  later 
years,  of  mental  twists  and  habits  formed  in  childhood,  not  / 
in  their  own  form,  but  strangely  altered  and  concealed. 
The  principle  itself  is  familiar  enough,  but  it  is  to  the  keen- 
ness and  genius  of  Freud  that  we  owe  its  working  out  in 
ways  which  must  indeed  be  tested  further,  but  which  are 
certain  to  be  of  great  utility,  both  in  helping  us  to  under- 
s  stand  character  and  to  treat  its  morbid  modifications.  - 
Underneath  the  cloak  of  fears  and  terrors  we  are  taught  by 
this  writer  to  seek  for  the  hidden  element  of  desire,  and  are 
given  directions  for  the  search  which  demand  our  thoughtful 
consideration. 

It  might  appear  from  these  remarks  that  I  regard  the 
psychological  method  as  the  only  one  likely  to  help  us  in  this 
study  of  character  and  its  treatment,  and  likewise  that  the 
sole  use  of  the  tendencies  to  reaction  that  deserve  the  name 
of  character  is  to  secure  an  adaptation  to  a  given  environment. 
But  this  is  by  no  means  true.  In  the  first  place  our  knowl- 
edge has  not  yet  reached  so  far  but  that  our  instinctive 
f  judgment  outstrips  it  still  at  many  points.  Try  as  we  may 
to  explain  character  by  studying  its  genesis,  it  has  still  a 
meaning  which  is  certain  to  elude  our  critical  inquiry,  yet 


190  Psychotherapeutics 

which  we  strongly  feel.  In  the  next  place,  the  explanation 
of  the  progress  of  vital  processes  as  here  hinted  at,  does  not 
supply  the  meaning  of  life  nor  the  motives  for  living.  It  is 
one  of  the  great  mistakes  of  modern  science  to  assume  that 
we  can  get  on  without  interesting  ourselves  in  these  matters.  .- 
It  is  widely  thought  that  a  man  need  not  speculate  about  his 
origin  and  his  destiny,  or  upon  the  obligations  of  loyalty 
furnished  by  considerations  of  these  sorts.  These  senti- 
ments I  by  no  means  share.  I  think,  on  the  contrary,  that 
physicians  are  as  much  bound  to  study  philosophy  as 
psychology  and  to  carry  their  patients  with  them  so  far  as  it 
is  practicable  to  do  so,  through  this  path.  Then,  as  re- 
gards the  matter  of  adaptation,  I  believe  it  is  only  just  to 
speak  of  character  as  standing  for  adjustments  to  the  en- 
vironment if  we  are  ready  to  define  our  environment  in  a 
broader  way  than  it  is  usually  defined.  We  are  surrounded 
by  a  world  of  spirit  just  as  obvious  as  the  world  of  matter 
to  anyone  who  has  the  knowledge  and  willingness  to  probe 
beneath  the  surface,  and  possessed  of  a  reality  more  basal 
than  any  reality  that  it  is  possible  to  assign  to  the  material 
world,  considered  in  and  for  itself. 

Excellence  of  character,  then,  is  definable  with  reference 
to  the  degree  to  which  it  represents  all  the  different  portions 
of  a  person's  history  and  nature,  and  may  be  defined  as  of 
a  better  sort  the  more  completely  it  implies  3  unification  of 
the  powers,  physical,  and  mental,  of  which  he  is  composed, 
and  the  more  it  indicates  that  he  is  capable  of  adapting 
himself  to  a  variety  of  environments.  But  these  environ- 
ments must  not  be  purely  of  a  material  sort.  The  indi- 
vidual possessed  of  the  best  form  of  character  must  be 
suited  not  alone  to  the  environment  which  he  sees  but  to 
an  environment  which  he  imagines  with  the  vision  of  an  • 
intelligent  and  critical  idealist. 

The  treatment  of  patients  from  the  point  of  view  of 
character  is  then  identical  with  the  treatmentof  them  as  partial 


Relation  of  Character  Formation  to  Psychotherapy     191 

neurasthenics,  hysterics,  or  psychasthenics,  etc.,  on  the  one 
hand,  and  as  individuals  standing  in  need  of  a  broader  vision, 
on  the  other. 

A  man's  character  is  not  something  superadded  to  his  \ 
other  qualities,  something  capable  of  existing  independently  f 
and  to  be  recognized  in  and  for  itself.     It  is  only  pictur- 
esquely  and  for  convenience'  sake  that  we  speak  of  char- 
acter as  of  a  sort  of  seal  stamped  on  the  record  of  a  person's 
life,  a  diploma  of  success  or  failure,  granted  from  without. 
Each  one  of  a  man's  acts  is  the  outcome  of  all  the  acts  that 
have  preceded  it  in  the  past,  plus  a  quality  derived  from  free 
^choice.     This  free  choice  is  based  partly  on  a  divination  of 
the   future,   or  —  to   speak   more   accurately  —  on   a   half- 
unconscious  recasting  of  the  present  in  terms  of  a  wider 
order  than  that  which  is  represented  by  experience  alone. 
We  outside  observers  compare  and  contrast  a  series  of  such 
acts   and  when  we  find  that  there  are  features  common  to 
them  all  or  to  large  groups  of  them,  we  collect  and  name 
these  common  features,  and  thus  assume  for  them  by  im-  / 
plication    a  separateness  of  existence  which   in  fact  they-, 
cannot  claim.     In  reality  every  act  represents  an  indivisible  j 
effort  of  the  actor's  mind,  and  it  is  only  by  abstraction  that  [ 
we  assign  a  definite  portion  of  a  given  result  to  the  man's  I 
character. 

From  a  single  base  an  infinite  number  of  triangles  can 
be  drawn,  and  all  will  have  something  in  common  though 
each  may  be  conceived  of  as  independent  of  the  rest.  And 
so  may  the  same  basal  elements  of  character  permeate  an 
infinite  number  of  single  acts,  each  of  which  has  an  autonomy 
of  its  own. 

When  we  state,  then,  in  respect  to  a  person's  intellectual, 
emotional,  or  volitional  life,  that  it  has  this  or  that  character, 
we  render,  primarily,  a  judgment  based  on  observation  of 
his  conduct  under  various  conditions.  But  this  judgment 
contains  also  an  implied  belief  that  his  conduct  owed  its 


192  Psychotherapeutics 

existence  to  the  influence  of  certain  sets  of  causes.  Thus 
when  we  speak  of  a  person  as  being  of  "  good  "  character 
or  as  being  "  able,"  or  "  courageous,"  or  the  reverse,  we 
instinctively  think  of  him  as  having  inherited  certain  traits 
or  as  having  been  exposed  to  influences  which  helped  to  make 
him  habitually  act  in  certain  ways. 

Both  these  elements  in  our  judgments  of  a  person's 
character  are  subject  to  considerable  error,  but  this  applies 
especially  to  the  second  element,  that  which  deals  with  the 
genesis  of  character. 

The  statement  of  a  person's  character  thus  assumes  to 

give  an  epitome  of  his  past  and  a  forecast  of  his  future.     A 

forecast  of  his  future,  because  in  the  acts  and  attitudes  of 

j  every  individual  something  of  his  own   divination  of  his 

I  future  is  contained  and  actually  exerts  an  effective  force, 

and  thus  communicates  a  portion  of  the  tendencies  that  make 

up  his  character.     It  is  just  this  power  to  penetrate  the 

future  that  measures  and  constitutes  a  man's  free  will. 

It  follows  from  what  has  just  been  said  that  it  is  only  as  a 
figure  of  speech  that  it  is  justifiable  to  speak  of  attempts  to 
form  character  as  in  the  sense  of  seeking  to  reach  a  clearly 
defined  goal.  If  a  valid  character  is  the  outcome  of  valid 
acts  done  in  the  past,  modified  at  every  turn  by  free  choices 
made  in  the  interests  of  a  higher  order,  then  we  can  gain 
character  only  in  one  way,  namely,  through  our  acts.  It 
would  be  an  ignoble  effort,  and  one  certain  to  defeat  itself, 
to  attempt  to  gain  the  favorable  judgment  of  others  as  a 
species  of  personal  asset,  in  any  other  mode  than  this.  The 
habit  or  tendency  to  react  in  a  desirable  manner  is  formed 
as  the  result  of  a  long  series  of  thoughts,  purposes,  and 
sentiments  genuinely  entertained  and  efforts  effectively 
carried  out.  A  person  who  would  reach  the  same  result, 
and  who  would  be  recognized  as  having  reached  it,  should 
seek  it  by  following  a  similar  road  in  the  same  genuine 
spirit.  But  this  road  is  not  one  mapped  out  in  advance. 


Relation  of  Character  Formation  to  Psychotherapy     193 

Each  person  builds  it  as  he  goes,  through  acting  out  his  own 
nature.     Neither  can  the  goal  be  foreseen  except  in  very 
general  terms.     As  the  needs  change  so  do  our  acts  and  pur- 
poses shift  and  become  modified,  and  so  likewise  our  char- 
acter.    For  a  man's  character  is  a  sort  of  composite  photo-i,, 
graph  of  his  life.     The  portrait  is  bound  to  be  genuine,/ 
whether  the  elements  to  be  portrayed  represent  genuineness 
and  consistency  in  the  ordinary  moral  or   intellectual  sense, 
or  lack  of  genuineness  and  inconsistency,  effectiveness  or 
ineffectiveness. 

The  more  symmetrical,  unified,  and  adequate  a  man's 
development  has  been,  the  more  consistent  is  his  conduct.  - 
On  the  other  hand,  not  only  the  best  in  each  person  but  also 
the  worst  and  the  indifferent  elements  in  him  necessarily 
/  play  a  hand  in  this  game.  Fortunately,  in  the  continual 
melting  up  and  remelting  that  goes  on  within  the  crucible 
of  progress,  the  worst  may  be  made  eventually  an  element 
of  the  best,  but,  for  the  time  being,  if  it  becomes  a  fixed 
habit  to  be  trivial  that  habit  will  be  faithfully  represented 
in  a  person's  character,  for  this  represents  the  master  habit 
of  his  habits,  the  master  tendency  of  his  tendencies.  There 
is  no  room  for  deception  in  the  judgments  of  that  court. 

A  person's  character  is,  however,  not  always  just  the 
same.  It  presents  itself  under  different  forms,  corresponding 
to  the  changing  aspects  of  his  personality  and  his  moods, 
though  shifting  less  than  they,  just  as  the  trunk  of  a  tree 
moves  less  than  the  branches.  Each  phase  of  a  multiple 
personality  has  its  own  character,  and  these  phases  reappear  as 
quasi  normal  moods.  The  severe  test  of  illness  sometimes  de- 
velops forms  of  character  that  otherwise  might  have  remained 
^undeveloped.  Within  the  orbit  of  the  invalid,  which  includes 
the  doctor  and  the  nurse,  selfishness  sometimes  reigns  and 
narrow  egotism,  together  wth  sentimentality,  ignorance, 
and  weakness  of  the  will,  and  these  tendencies  may  remain 
active  long  enough  to  make  themselves  felt  through  modifi- 


194  Psychotherapeutics 

cations  of  the  character.  But, —  what  is  more  important 
for  our  purposes, —  unselfishness,  devotion,  willing  sacrifice 
of  ambitions  and  desires,  thoughtfulness,  persistent  effort, 
loyalty,  the  sense  of  service,  may  likewise  be  manifested 
here,  in  their  best  form.  The  invalid  may  make  excursions 
into  certain  realms  which  are  rarely  open  to  the  well  and 
strong. 

There  are  forms  of  character  in  which  patience  is  unified 
with  clear  intelligence  and  strong  will,  with  instincts  which 
have  found  natural  expression  and  ideals  which  have  grown 
broader  with  experience.  The  possessor  of  such  a  character 
as  this  has  at  his  command  a  means  of  combating  illness, 
a  compensation  for  illness,  and  a  safeguard  against  certain 
forms  of  illness,  which  are  of  inestimable  value.  These  aids 
are  needed,  for  the  tests  to  which  the  invalid  is  exposed  are 
serious  tests.  Pain,  disappointment,  the  necessity  of  sac- 
I  rificing  cherished  hopes;  the  necessity  of  ceaseless  struggles 
j  with  the  sense  of  weakness,  of  exhaustion,  of  isolation;  the 
•  necessity  of  living  in  almost  perpetual  companionship  with 
some  parasite  or  demon  or  phantom  of  the  fancy,  hardly 
less  hard  to  bear  for  being  recognized  as  fictitious;  harder 
still,  the  tearing  asunder  of  strong  ties  of  family  and  friend- 
ship; trials  such  as  these  may  mar,  but  often  make  a  fine 
character,  and  many  examples  of  the  latter  result  are  known 
to  all.  Such  persons  are  'unified  '  to  a  remarkable  degree. 
The  syntheses  that  represent  each  one,  even  of  their  more 
trivial  acts  are  enriched  and  animated  by  similar  memories 
and  motives.  The  emotional  'core'  of  each  harmonizes 
readily  with  all  the  rest. 

But,  it  might  be  urged,  to  what  purpose  cite  the  examples 
of  eminent  heroes  of  invalidism  if  it  is  an  impossible  task  for 

{most  of  us  to  follow  where  they  have  led  ?  If  our  characters 
depend  so  much  on  our  inherited  traits  and  on  instincts 
arising  at  the  very  threshold  of  infancy  that  our  very  carriage 
and  gestures,  our  voices,  and  the  expressions  of  our  faces 


Relation  of  Character  Formation  to  Psychotherapy     195 

reveal  our  natures  and  stamp  us  to  the  casual  observer  for 
what  we  are,  why  should  we  fret  ourselves  with  vain  attempts 
at  change  ?  We  cannot  change  our  bodies,  how,  then,  can 
we  hope  to  alter  our  characters,  some  elements  of  which  are 

V  almost  as  fixed  as  our  spinal  reflexes  themselves  ?  The  most 
trivial  habits,  even  if  recently  acquired,  obstinately  resist 
dismissal,  and  the  same  is  still  more  true  of  our  obsessions. 
The  causes  of  many  of  our  abnormal  traits  lie  out  of  reach, 
it  is  said,  buried  in  the  form  of  bodily  mechanisms  and  for- 
gotten experiences  of  the  past.  Timidity,  vanity,  selfishness, 
may  be  graven  so  deeply  into  our  lives  that  although  we  can 
conceal  them  for  a  certain  period  it  is  often  claimed  that  we 
cannot  eradicate  them  altogether. 

So  strongly  do  many  persons  feel  that  a  man's  character 
is  in  many  ways  outside  of  his  control,  that  the  very  knowl- 
edge that  he  belongs  to  a  certain  family,  even  to  a  certain 
race,  is  enough  to  make  them  doubt  his  capacity  for  any 
considerable  change.  Various  students  of  heredity  rate 
the  influence  of  education,  very  low  *  as  compared  with  that 
of  hereditary  tendencies.  Even  admitting  that  a  real  chang- 
ing of  the  character  is  possible,  the  invalid  —  many  men 
would  say  —  is  heavily  handicapped  for  such  a  struggle. 
His  inheritance  may  be  dark,  his  interests  narrow,  his 
opportunities  for  mingling  actively  in  the  stimulating  game 
of  life  and  feeling  the  warm  breath  of  others'  zeal  are 
relatively  few.  He  must  often  stand  by  and  "  look  on  with 
cold  hands  while  they  join  in  the  whirling  game."  He  is 
tempted,  pushed  and  drawn  towards  a  life  of  selfishness, 

I  discouragement,  and  inertness.  But,  fortunately,  there  is 
another  and  very  different  side  to  this  picture,  and  one  which 
both  science  and  observation  contribute  the  materials  for 
painting.  The  argument  for  the  inalterability  of  the  funda- 
mental tendencies  to  conduct  is  unsound;  the  motives  and 
opportunities  present  to  the  invalid  are  inaccurately  stated. 
Character  is  to  be  measured  in  terms,  not  of  quantity,  but  of 
*Cf.  Heredity  in  Royalty.  Woods. 


196  Psychotherapeutics 

quality.  What  a  person  needs  in  order  to  fulfill  his  destiny, 
to  reach  his  goal,  whether  in  a  personal  sense  or  with 
reference  to  his  obligations  towards  the  world,  is  a  powej 
of  insight  and  a  sense  of  progress  and  freedom,  rather  than 
any  special  form  of  external  accomplishment.  There  are 
many  kinds  of  insight  and  many  doors  and  avenues  to  the 
realms  of  freedom.  It  is  only  necessary  to  look  at  the  j 
invalids  who  have  accepted  their  conditions  cheerfully  and 
taken  their  lot  at  its  best,  to  realize  what  possibilities  are  " 
open  to  those  who  can  escape  from  estimating  the  pleasure 
and  value  of  their  lives  in  too  conventional  terms. 

We  see  daily,  to  be  sure,  persons  who  refuse  to  regard 
sickness  in  any  light  except  as  an  obstacle  and  a  misfortune 
of  a  wholly  different  class  from  those  of  a  more  familiar  sort, 
and  in  whom  it  excites  no  note  of  response  other  than  that 
of  terror  or  indignation.  Overwhelmed  by  a  sense  of  isola- 
tion and  of  personal  grievance,  they  can  do  nothing  but 
repine.  But  very  different  is  the  picture  presented  by  those 
persons  whose  characters  are  so  made  that  they  move 
forward  in  spite  of  the  handicap  of  illness,  so  steadily  that  like 
a  stream  of  water  poured  upon  the  ground,  which  finds  itself  .' 
met  by  one  obstacle  after  another  only  to  turn  in  a  new 
direction  and  pass  on,  while  the  idea  of  being  conquered  or 
permanently  checked  seems  not  to  present  itself  before  their 
minds.  The  characters  of  such  persons  may  vary  greatly  in 
detail,  but  they  resemble  each  other  in  the  respect  that  they 
all  point  to  more  or  less  effectively  unified  personalities, 
to  a  fairly  concurrent  action  of  the  multifold  tendencies 
through  which  their  actions  are  determined. 

Even  faults,  failures,  and  defects  have  no  prescriptive 
right  to  bar  one's  way  to  a  larger  view  of  illness  or  of  trouble, 
and  should  not  be  allowed  to  do  so.  Morbid  self-conscious- 
ness, egotism,  the  tendency  to  follow  aims  less  desirable  than 
the  best,  unwelcome  as  they  are,  should  nevertheless  be 
actually  welcomed,  if,  as  so  often  happens,  they  mean 


Relation  of  Character  Formation  to  Psychotherapy     197 

movement  and  progress.  The  outlook  for  the  invalid  is 
also  for  another  reason  much  better  than  it  is  frequently 
pictured.  The  dead  hand  of  an  inheritance,  assumed  (usually 
on  very  insufficient  grounds)  to  be  "  morbid,"  of  habits 
supposed  to  be  unalterably  fixed,  often  owes  its  baleful  power 
to  the  fact  that  its  workings  are  concealed  from  us. 

It  is  the  skeleton  in  the  closet,  the  tug  of  an  evil  spirit 
residing  in  the  mysterious  depths  of  our  subconscious  life, 
the  misunderstood  twists  and  tendencies  derived  from  un- 
fortunate experiences  in  childhood,  experiences  which  at  the 
time  may  have  seemed  innocent  and  trivial  enough  —  that 
contribute  many  of  the  specters  which  terrify  us  and  seem 
to  block  our  paths.  It  is  among  the  best  contributions  of 
modern  psychiatry  and  psychotherapy  that  it  has  been 
shown  to  be  possible,  in  a  remarkable  degree,  to  reverse 
these  hidden  influences,  which  are  due  to  old  environments, 
to  misinterpreted  emotions, —  in  brief,  to  ignorance.  The 
discovery  that  even  patients  with  dementia  precox  can  be 
measurably  helped  through  application  of  this  principle 
is  one  of  the  encouraging  developments  of  modern  medicine. 
The  invalid  who  finds  himself  in  face  of  difficulties 
which  seem  so  hard  to  overcome  is  drawn  forward  and  held 
back  by  strong  and  varied  groups  of  impulses  in  which  good 
and  evil,  basal  instincts  and  fresh  ideals,  traditions  of  courage 
and  traditions  of  cowardice,  confidence,  and  terror,  love  of 
\  his  fellowmen  and  fear  of  his  fellowmen,  freedom  and  preju- 
;  dice,  seem  to  be  joined  in  combat  for  the  formation  of  his 
character.  The  physician's  duty  is  to  aid  him  in  discovering 
his  best  birthright,  in  helping  his  best  instincts,  the  best 
fruits  of  his  intelligence,  the  best  conquests  of  his  will,  to 
gain  the  mastery. 

The  habits  that  we  seek  to  alter,  after  all,  are  habits 

only.     They  reside  in  the  physiological  mechanism  of  our 

bodies,  and  these,  just  because  they  live,  are  more  or  less 

;  susceptible  of  change.     I  recall  an  interesting  conversation 


198  Psychotherapeutics 

with  an  able  student  of  these  subjects  with  relation  to  the 
bodily  signs  of  neurasthenic  states,  and  remember  well  his 
agreement  with  my  view  that  many  of  them,  deep-seated 
though  they  seem  to  be,  are  susceptible  of  modification  in  the 
direction  of  more  normal  nutritive  development,  provided 
only  that  their  mental  accompaniments  can  be  improved. 
f  The  bare  fact,  indeed,  that  the  nutrition  of  the  body  can  be 
modified,  even  in  its  most  intimate  forms,  through  the  action 
v-<pf  mental  states,  is  too  well  acknowledged  to  need  further 
emphasis. 

Every  one  has  seen  individuals  whose  characters  have 
been  so  changed  through  development  that  for  all  practical 
purposes  they  have  become  fundamentally  different  from 
what  they  had  been  before.  In  many  of  these  cases  the 
influence  of  illness  has  been  one  means  through  which  this 
change  was  brought  about.  The  mode  in  which  the  change 
takes  place  seems  usually  to  be  one  of  either  of  two  sorts. 
First,  the  former  traits  of  character  are,  as  it  were,  side- 
tracked by  the  formation  of  new  habits,  a  new  personality^ 
dependent  on  new  interests  and  developed  in  practical  sub- 
stitution for  the  old.  Next,  the  new  character  may  absorb 
the  old;  as  when  a  person  utilizes,  more  or  less  consciously, 
all  the  influences,  painful  as  well  as  pleasurable,  which  have 
been  brought  to  bear  upon  him,  and  makes  his  faults  as  well 
as  his  virtues,  his  weakness  as  well  as  his  strength,  materials 
for  the  formation  of  a  new  character  which  without  these 
influences  could  not  have  been  formed.  Intensely  self- 
conscious  persons  of  the  type  of  Bunyan  are  among  those 
who  adopt  this  latter  plan,  and  there  are  various  other  types 
of  invalids  whose  development  follows  similar  lines. 

Whichever  of  these  two  modes  of  effecting  a  change 
in  the  fundamental  movements  of  one's  life  is  chosen,  three 
great  influences,  sanctioned  alike  by  the  experience  of  edu- 
cators and  the  observation  of  physicians  who  have  dealt 
with  morbid  minds,  must  be  mainly  relied  upon  in  the  ac- 


Relation  of  Character  Formation  to  Psychotherapy     199 

complishment  of  the  task.  These  are,  on  the  one  hand,  the 
utilization  of  emotions,  desires,  strong  interests,  enthusiasm, 
even  the  enthusiasm  attending  intellectual  convictions  of 
a  high  order;  on  the  other  hand,  persistent,  arduous,  and 
thorough  training,  carried  out  under  a  clear  conception  of 
the  difficulties  in  the  way;  and,  finally,  the  eradicating  of 
hidden  obstacles  to  success  residing  in  the  form  of  motor 
habits  and  memories  not  clearly  present  before  the  waking 
consciousness.  The  principles  underlying  these  three 
methods  need  to  be  separately  considered. 

To  speak,  first,  of  the  "  side-tracking  "  plan,  it  is  ob- 
vious that  if  the  invalid  is  to  be  led  to  adopt  new  interests, 
to  gain  new  enthusiasms  of  sufficient  strength  and  enduring 
power  to  modify  his  character,  these  interests  and  enthu- 
siasms must  be  in  harmony  with  his  own  nature;  he  cannot 
be  expected  to  form  a  wholly  artificial  self.  And  yet  by 
assumption  he  is  cut  ofF  from  many  of  the  special  interests 
and  pleasures  prominent  in  other  persons'  lives  and  perhaps 
previously  in  his  own.  If  success  is  to  be  obtained  it  must 
be  because  every  person's  nature  is  in  reality  far  broader]  „ 
than  at  first  appears.  There  are  persons  who  appear  able, — " 
not  merely  as  a  matter  of  hypocritical  pretense,  but  actually — 
to  feel  their  interests  merged  in  the  interests  of  the  com- 
munity, taken  in  a  larger  or  a  narrower  sense.  Parents 
usually  care  intensely  for  the  happiness  of  their  children, 
and  do  not  feel  aggrieved  and  depressed  if  they  are  obliged 
to  sacrifice  lesser  personal  interests  for  interests  of  this  greater 
sort.  Citizens,  and  even  races,  in  whom  the  sentiment  of 
patriotism  has  been  strongly  developed,  work  and  die, 
cheerfully  and  loyally,  for  national  successes  that  they  will 
never  see.  These  community  sentiments,  which  are  thus 
so  strong,  may  take  a  definitely  personal  or  a  relatively  im- 
personal form.  If,  now,  some  persons  are  so  powerfully 
moved  by  these  feelings,  it  must  be  that  all  persons  are 
capable  of  responding  to  them,  and  that  the  physician's 


, 


20O  Psychotherapeutics 

problem  is  to  find  means  of  rousing  these  sentiments  into 
flame.  I  believe  that  the  difficulty  in  the  way  of  this  result 
consists  less  in  overcoming  an  essential  resistance  than  in 
overcoming  conventional  habits  of  thought  and  feeling. 

The  fear  of  others'  criticisms  makes  us  cold.  Our 
conventional  views  of  success,  misfortune,  death,  are  too 
often  irrational  and  even  positively  low,  and  it  is  custom 
'  more  than  nature  that  makes  them  so.  The  very  fact  that  the 
habit  of  esteeming  the  community  success  or  the  success  of  a 
cause  as  preferable  to  personal  success  may  become,  within 
certain  limits,  a  national  habit,  is  a  sort  of  warrant  for  the 
possibility  of  exciting  it  in  a  given  case.  Invalids  should 
learn  to  regard  themselves  as  members  of  an  imaginary  band 
of  persons,  inspired  by  loyalty  to  sentiments  of  health  and 
courage,  although,  like  themselves,  obliged  to  carry  burdens 
of  a  certain  sort.  The  numerous  individuals  who  suffer  from 
ideas  of  morbid  self-consciousness  carry  about  with  them 
a  band  of  imaginary  critics  and  enemies,  and  can  often 
substitute  for  them  without  great  difficulty  this  ideal  band 
of  allies.  It  is  a  question  of  gaining  new  ideals  of  living 
and  making  these  ideals  actually  count  as  standards.  "  I 
have  tried  to  live  so  that  my  smallest  act  would  correspond 
to  my  highest  ideal,"  wrote  an  intelligent  patient  with  whom 
this  sentiment  had  become  the  prevailing  motive  of  her 
thoughts  and  conduct. 

Every  invalid  has  also  many  capacities  for  genuine 
interest  and  pleasure  of  the  lighter  sorts,  which  are  capable 
of  exciting  enthusiasm  if  only  they  are  followed  without  the 
reserve  induced  by  conventional  restraints  and  by  the  habit 
of  comparison  of  one's  self  with  others.  In  the  way  of  this 
result  stands  the  instinctive  longing  for  individual  success, 
misunderstood  and  taken  in  an  exclusive  and  personal  sense, 
as  if  one  man's  success  must  mean  another's  failure.  Per- 
sonal courage  and  personal  energy  and  enterprise  do  indeed 
seem  to  stand  at  the  very  center  of  all  progress,  but  they 


Relation  of  Character  Formation  to  Psychotherapy    201 

connote  much  that  is  barbarous  and  need  the  counter- 
balancing note  of  the  "courage  to  let  the  courage  sink."  *  We 
continually  underrate  or  wholly  fail  to  recognize  the  deeper 
motives  by  which  we  might  be  impelled.  We  like  too  well 
to  imagine  that  our  lives  and  impulses  are  clear  before  us, 
and  to  gain  this  seeming  clearness  we  close  our  eyes  to  great 
masses  of  influences  which  it  would  cost  us  much  pains  and 
perhaps  pain  to  analyze. 

It  is  obvious  from  what  has  been  said  that  character 
serves  as  a  stimulus  to  action.  It  is  likewise  known  that 
through  experimental  methods,  as  in  the  case  of  a  hypnotized 
patient,  it  is  possible  to  secure  impulses  to  action  which, 
primarily  at  least,  do  not  deserve  the  name  of  character  or 
even  of  emotional  interest.  In  other  words,  it  has  been 
found  that  any  positive  suggestion  made  when  the  mind  is 
in  a  receptive  state  is  likely  to  be  carried  into  execution.  In 
fact,  the  attempt  has  been  made  to  form  character  through 
"  suggestion,"  especially  with  children,  and  it  is  indeed 
possible  that  certain  steps  in  this  progress  can  be  thus  ac- 
complished. It  is,  however,  instructive  to  note  that  there  is 
a  striking  difference  between  the  impulses  to  action  formed 
through  suggestion  and  those  gained  through  experience  and 
struggle,  even  though  the  apparent  result  and  form  of  the 
action  might  seem,  now  and  then,  to  be  the  same  in  the  two 
cases.  This  difference  resides  in  the  fact  that  although  an 
impulse  to  action  secured  through  suggestion  may  fit  us  to 
carry  out  a  certain  result,  and  thus  make  us  adapted  for  a 
definite  environment,  the  position  of  character  —  assuming, 
of  course,  that  it  is  character  of  a  desirable  sort  —  adapts  us 
for  environments  of  many  sorts.  The  memories  of  the 
experiences  through  which  a  person  has  passed,  under  these 
circumstances,  come  to  his  aid  in  the  way  of  enriching  his 
perceptions  and  his  thoughts,  to  an  extent  which  it  would 
be  otherwise  impossible. 

The  second  of  the  two  methods  of  character  modification 

*Arthur  H.  Clough. 


2O2  Psychotherapeutics 

consists  in  the  systematic  study  of  one's  personal  experiences 
and  traits  in  the  interest  of  an  outcome  better  than  the 
present.  Much  has  been  said  of  the  evils  of  introspection, 
and  this  would  seem  to  imply  introspection  on  a  large  scale. 
But  there  are  two  sorts  of  introspection.  One  of  them  is 
simply  emotional,  morbid,  and  depressing,  and  ends  in 
nothing  that  is  useful,  while  the  other  is  a  thoughtful  study  of 
one's  self,  made  desirable  either  for  the  sake  of  increasing 
the  general  sum  of  knowledge,  or  for  the  sake  of  the  correc- 
tion of  tendencies  which  absolutely  need  correction.  This 
self-investigation,  which  is  much  better  conducted  with  the 
aid  of  the  skilled  physician,  may  take  either  one  of  two 
forms.  The  patient  may  scrutinize  the  obstacles  consisting 
in  his  own  peculiarities  of  disposition  and  of  habits,  and  learn 
to  estimate  them  at  their  true  value,  regarding  them,  so  far 
as  practicable,  in  a  matter  of  fact  way  and  without  undue 
emotion,  especially  without  self-reproach,  and  may  utilize 
the  information  that  he  gains  in  the  interests  of  progress. 
Or,  he  may  make  a  very  thorough  scrutiny  of  the  origin  of 
his  symptoms,  be  they  what  they  may, —  morbid  self-con- 
sciousness, fears,  undesirable  feelings  toward  those  around 
him,  dissociations  of  the  hysterical  type.  Every  thoughtful 
person  is  aware  that  many  of  these  symptoms  have  their 
roots  in  experiences  and  habits  formed  in  childhood,  but 
there  are  few  persons,  even  though  thoughtful,  who  have  as 
yet  learned  to  appreciate  the  full  bearing  of  this  principle. 
Mental  conflicts  may  begin  almost  in  the  cradle,  and  are 
often  attended  or  soon  followed  by  desires,  aspirations,  and 
fears,  which  too  often  are  given  no  outlet,  but  are  ostensibly 
suppressed.  In  reality  this  suppression  means  frequently 
conversion  into  some  other  form  and  the  establishment 
\  of  an  undesirable  tendency  to  morbid  growth.  The  paper 
of  this  series,  by  Dr.  Ernest  Jones,  describes  this  principle 
with  far  better  justice  than  I  can  render  it  in  these  few  lines. 
I  will  only  say  that  the  longer  I  have  studied  the  matters  of 


Relation  of  Character  Formation  to  Psychotherapy    203 

which  his  paper  treats,  the  more  fully  I  am  convinced  of  their 
significance.  I  have  already  discussed  them  somewhat  in 
the  earlier  portion  of  this  paper. 

Besides  these  two  great  methods  of  character  formation, ; 
that  which  operates  through  the  operation  of  new  interests 
and  that  which  operates  through  the  scrutiny  of  past  experi- 
ences and  present  peculiarities, —  there  is  a  large  field  for 
efforts  toward  character-formation  through  the  systematic 
training  of  the  will  and  the  assumption  of  duties  and  obliga-/ 
tions  toward  individuals  and  the  community. 

Back  of  them  all,  however,  lie  the  question  and  the 
doubt,  "  Do  we  mean  to  substantiate  our  principles  with 
acts  "  ?  "Are  we  prepared  to  pay  the  price,  in  labor,  of 
freedom  and  self-control  ? "  If  these  questions  can  be 
honestly  answered  in  the  affirmative,  the  battle  is  half  won. 
For  the  development  of  character  in  harmony  with  new 
ideals  and  needs  it  is  not  necessary  or  desirable  to  eradicate 
the  past,  but  only  to  make  it  lend  some  element  of  value  to 
X:he  present.  The  oriental  philosophy  would  see  virtut 
reached  through  the  obliteration  not  only  of  sensuality  but  of 
the  senses.  A  typical  reductio  ad  absurdum  of  this  principle 
is  furnished  by  the  conduct  of  those  devotees  who  have  them- 
selves immured  in  narrow  cells  to  be  thereafter  kept  alive  for 
varying  periods  through  food  thrust  in  by  narrow  apertures. 
The  Western  philosophy  adopts  sense  pleasures  as  ele- 
ments to  be  utilized;  adopts  the  seeming  paradox  that  sins 
and  pains,  even  if  apparently  useless,  are  not  incompatible 
with  the  theory  of  a  moral  universe.  The  man  of  finest 
x  character  has  long  ceased  to  be  sensual;  yet  he  does  not, 
for  that,  shut  his  eyes  upon  his  natural  instincts,  but  remains 
sense  free  and  sense  active,  and  recognizes  the  splendid 
working  out  of  sense  instincts  in  civilization  and  community 
life.  Neither  do  the  temptations  and  trials  of  illness  and 
misfortune  fetter  his  thought  any  more  than  the  temptations 
of  sensuality. 


204  Psychotherapeutics 

The  development  of  character  in  a  desired  direction  is 
then  to  be  secured  through  free  choice,  but,  as  a  rule,  slowly, 
perhaps  painfully,  and  under  constant  vigilance  and  effort.* 
Most  of  all,  the  principle  should  be  recognized  that  in  the 
conscious  attempt  to  modify  character  and  to  escape  from 
the  bondage  of  hampering  habits,  what  we  really  seek  is  not 
the  destruction  of  order,  in  the  supposed  interests  of  freedom, 
but  acceptance  of  a  more  comprehensive  order  as  the  highest 
choice  of  freedom.  It  is  the  conception,  under  the  form 
of  an  ideal  vision,  of  this  higher  order,  combined  with  the 
power  which  the  vision  furnishes  of  seeing  one's  self  as  part 
of  a  larger  whole,  one  member  of  a  great  company  of  persons 
not  wholly  describable  in  terms  of  bodily  forms,  a  company 
whose  pleasures  and  progress  each  one  may  enjoy,  regard- 
less of  his  individual  lot;  it  is  this  conception  that  makes  * 
illness  not  only  bearable,  but  sometimes  the  road  to  a  more 
satisfactory  sort  of  health. 

*  It  is  interesting  to  note  that  Dante,  in  his  Purgatorio,  while  asserting 
the  possibility  of  progress,  symbolizes,  by  the  lengths  of  time  which  he 
assumes  to  be  required  for  his  modifications  of  character,  the  practical  diffi- 
culty in  the  way  of  the  result. 


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